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Chapter 2: A Systems Perspective of Quality Management

ever, when the compounding effect of this cost-cutting strategy is viewed ss the entire organization, the strategy designed to reduce costs actually ermines the organization's ability to do so (Kelly 1999).

mmary e the term "quality," the term "system" can carry a variety of conno- ions. In this text, a system refers to a collection of parts that interact :ili each other to form an interdependent whole, and systems thinking

owledges the large number of parts in a system, the infinite number of ys in which the parts interact, and the nature of the interactions. The five

_ em characteristics contributing to the presence of dynamic complexity change, trade-offs, history dependency, tight coupling, and nonlinearity.

ercise bjective: To practice identifying dynamic complexity.

...n.structions: Describe how the following examples illustrate dynamic complexity.

Example 1: =Hurricane Katrina devastated economies, communities, families and indi- iduals along the US Gulf coast in 2005. Although the levees in New Orleans ere known to be vulnerable (Fischetti 2001), policymakers chose not to

- vest the resources needed to strengthen them. The failure of the levees and e flooding that followed have led to the most expensive urban recovery and building effort in US history. Federal dollars that now must rebuild the attered coast are no longer available to fund daycare centers, school lunch

_rograms, Medicaid or nursing research. People fleeing from the Gulf coast evacuated to communities throughout the United States. On arrival in places such as Atlanta and Houston, they needed health services and replacement o essential prescription drugs-and most had no health records or insurance informarion ... documents that would normally be essential."

From: Mason, K. D., J. K. Leavitt, and M. W. Chaffee. 2007. "Policy & Politics:A Framework for Action." In Policy &Politics in Nursing and Health Care, edited by K. D. Mason, J. K. Leavitt, and M. W. Chaffee, 1-20. St. Louis, MO: Elsevier.

Example 2: =Hospitals nationwide are tangling with Wall Street to get out of disastrous wages that have complicated their financial problems. Some hospitals are paying millions of dollars in penalties to get out of derivatives contracts, after betting incorrectly that interest rates would rise. Other hospitals are paying

------' "II Section III: Practice Lab Case Study This case is adapted from Kelly, D. L., and S. L. Pestotnik.. 1 Causal Loop Diagrams to Facilitate Double Loop Learning in the :::.;:-::.:::,;;;w. Delivery Setting." Unpublished manuscript.

Mrs. B was a 66-year-old widow living on a fixed inco - been diagnosed with high blood pressure and osteoporosis. F doctor knew her well. When he selected the medication with will her high blood pressure, he took into account her age, the fact .........,~'-_ osteoporosis, and other issues. He chose a drug that had pro en for patients like Mrs. B and that had minimum side effects. Mrs. " on the medication for ten years. Her insurance covered the c - medication, except for a small out-of-pocket copayment.

The last time Mrs. B went to her local pharmacy to refill her ~-_---- tion, the pharmacist informed her that her insurance company had CC:::=C::. with a pharmacy benefits management (PBM) company. (The role - company is to perform a variety of cost-cutting services for health •...--__'-'-_ plans. One of these services is to decide which drugs an insurance - will pay for; the PBM company's preferred-product list is known as - lary.) If Mrs. B wanted to continue to take the same medication =- cost her five times her usual copayment. She was quite disturbed be could not afford this price increase and did not fully understand her ance company's new policy. The pharmacist offered to call Mrs. B explain the situation, and ask him whether he would change her prf"cr~- to the PBM-preferred brand. When the physician was contacted, he aware of the PBM company's action and was not completely familiar - preferred product. The pharmacist discussed Mrs. B's predicament u- physician and described the financial consequences of her continuing to her original prescription. After this discussion with the pharmacist, the r cian concluded that his only option was to approve the switch, which h

Mrs. B began taking the new brand of high- blood-pressure me One week after starting on the new drug, she developed a persistent that aggravated her osteoporosis and caused her rib pain. When the and pain continued reSranother week, Mrs. B began to take over-the-co medicines for the pain. She unknowingly opened herself to a reaction be her blood pressure medication and the pain medication: orthostatic hy sion (lightheadedness when rising from a lying to an upright position). morning on her way to the bathroom, she fainted, fell, and broke her She was admitted to the hospital for surgery, where she developed a tract infection. The infection spread to her repaired hip, which resulted -- bloodstream infection that eventually led to her death.

that men:

Repeat 3

EXERCISE 4: MENTAL MODELS

Objective To practice identifying how mental models or assumptions influence behavior ill organizations.

nstructions See the Mental Models Worksheet at the end of this exercise. An example of a mental model associated with the "fighting fires" man- agement style in the context of a health services organization is fol- . lowed by actions associated with that mental model. Next, an alterna- tive (different, opposite) mental model for this type of management style is offered, followed by associated actions.

Choose the mental model that currently influences you or that you would like to influence your management approach and style. Circle that mental model on the worksheet.

Think of a mental model about the topic of "power and authority" in organizations. Describe your actions as a health services manager if your behavior was driven by this mental model. Think of an alter- native mental model about "power and authority" in organizations. Describe your actions as a health 1ervices manager if your behavior was driven by this mental model. Write your response in the respec- tive boxes on the worksheet.

Choose the mental model that currently influences you or that you would like to influence your management approach and style. Circle that mental model on the worksheet.

Repeat 3 and 4 for two topics of your own choice.

ERCISE 6: SYSTEMS ERROR CASE STUDY D ANALYSIS

jective - better understand Reason's Model of Organizational Accidents by iden- - ing different types of errors and interventions to prevent them from

ming an actual sentinel event.

tructions Read the article by Katherine Eban, "Your Hospital's Deadly Secret," available at: http://katherineeban.com/2008/03/01/your-hospitals-deadly- secret-conde-nast-portfolioy'.

Based on the information provided in the article, identify specific actions or decisions that proved to be errors at the different levels of the system. Write your responses in the first column of the worksheet that follows. Complete this column before moving on to question 3.

Identify specific interventions that would have helped the organiza- ion monitor or prevent the failures identified in the first column,.

from occurring. Write your response In the second column. Be very specific and concrete in your responses.

Refer to Chapter 4 and the Chapter 4 companion readings to assist you in completing this exercise.

("

II Section III: Practice Lab Organizational Errors Worksheet

Latent failures in the healthcare Leadership intervention to moc system level external to the hospital prevent failure from occurring and its parent company

Latent failures at the level of the Leadership intervention to mor:" organization's leadership prevent failure from occurring

Latent failures at the level of frontline Leadership intervention to monl management prevent failure from occurring

Workplace preconditions surrounding Leadership intervention to moni this event prevent failure from occurring

Active' errors associated with this Leadership intervention to monit ~ event , prevent failure from occurring

(7

c ..

jective

Identi in the