...Health Care Management Errors in a Post Modern/Complex Adaptive System MHA 601 Health Care Management Errors in a Post Modern/Complex Adaptive System Post modernistic/complex adaptive systems allow a leader a broader spectrum in which to examine a potential problem. In the past, problems in healthcare were presented and leaders used an absolute to correct the problem and move forward. Health care problems today are more complex and require a manager to think in terms bigger than just an absolute solution. “For the postmodernist, all models are only partial descriptions of reality, and scientific models are shaped not only by traditional scientific processes, but also by political, social, and personal interest,” (Johnson, 2009, p. 65). The following summaries of management errors will be examined as if management were that of a post modern/complex adaptive system. Scenario 1: A manager fails to account for employees’ ability to learn safe practices by experimenting on their own to increase productivity and jeopardize current standards put in place. This scenario is an error because the manager failed to see the inevitability of change. As resources become scarcer, employees are going to search for ways to increase their productivity as they feel more pressure to produce. A manger with a post modernist perspective would act as a change agent and anticipate the need for increased productivity and would implement the changes necessary prior to their staff experimenting...
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...Costa Concordia Anatomy of an organizational accident Jayvee M. Fernandez Maritime Law Midway Maritime Foundation ABSTRACT This paper analyses the grounding that occurred on the 13th of January 2012 to the cruise ship Costa Concordia. The analysis is carried out only on the conduct of navigation – and not on the emergency response - at three different levels: the errors of the bridge team, the error-inducing conditions of their workplace (the bridge), and the organizational processes behind them – following Reason’s (1997) model of organizational accident. An organizational accident is a rare, but often catastrophic, event that occurs within complex organizations as a product of technological innovation. Working under a hypothesis built on publicly available data till July 2012, the grounding of Costa Concordia appears to be an organizational accident. The paper aims to provide official investigators with a framework for the understanding of its development, which is considered critical to limit the re-occurrence of other such events. Moreover, it aspires to be the starting point for future examination of error inducing conditions across the cruising industry and the wider maritime domain. Overall, it is an attempt to address systemic issues, rather than accusing or defending individuals...
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...Influence of time pressure on aircraft maintenance errors TAKAHIRO SUZUKI, TERRY L. VON THADEN, WILLIAM D. GEIBEL University of Illinois at Urbana Champaign Introduction Even though proper maintenance is crucial for aviation safety, tracing the effect that human error in maintenance operations has on accidents and incidents remains a difficult task. According to a UK Civil Aviation Authority study (2003), maintenance and inspection deficiencies ranked fourth (12%) as a factor in aviation accidents overall. Other studies have described that as technology has improved, aviation accidents attributed to mechanical failures alone have decreased, yet those attributed to human error have not shown the same reduction (Wiegmann & Shappell, 2003). Aircraft maintenance requires high reliability and is an important concern in the human factors realm for several reasons. On the one hand, automation, which has reduced flight crew workload, does not apply in maintenance operations (Reason & Hobbs, 2003). On the other hand, maintenance tasks generally access critical areas where human errors lead to serious consequences (Reason, 1997). From a human factors perspective, in the current competitive environment of commercial aviation, occupational opportunities relating to aircraft maintenance technicians (AMTs) are declining. While oil prices soar, fares remain low due to competition (Bond, 2008). Employing fewer technicians and making turnaround at the airport gate shorter are...
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...done in a proper manner. Despite this oversight, maintenance errors still occur and have been, on many occasions, stated as the main cause of aircraft accidents. Knowledge of the factors that contribute to maintenance errors and therefore aircraft accidents can go a long way in enabling the industry regulars to draft precautionary measures and safety protocols to reduce the occurrence of these accidents. I. Factors contributing to maintenance errors Human factors, management factors, and structure factors are the most common factors that contribute to errors during the maintenance of aircraft (Stolzer, Halford & Goglia, 2012). Of the three factors, human factors account for the majority maintenance errors and therefore majority of aircraft accidents. There are numerous factors that can directly or indirectly contribute to human factors in maintenance errors can be categorized into the three groups of individual factors, job factors and organizational factors. Individual factors are those capabilities and attributes of an individual that may cause the individual to commit an error. These factors include their habits, personal attitudes, skills, personalities and their competence. For instance, if a maintenance officer has the habit of not paying close attention to detail, the officer may overlook a crucial maintenance steps that may later cause the aircraft to crash. Job factors that cause human maintenance errors are the workplace requirements that may not match the capabilities...
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...It is a management strategy which focuses on enhancing quality of not only the product, but also the customer satisfaction and all the processes in the organization, such as marketing, financing, manufacturing, training and so on. Its basic concept is that the entire company continuously aims to improve the quality as well as to reach the perfect quality associated with performance success and economic condition. TQM stresses the creative involvement of each person from CEO down, in the quest for quality. How can company succeed in ameliorating organizational performance? The process of TQM is the answer. Review of the Literature The notion of TQM was briefly introduced by Faigenbaum, he defines TQM as “an effective system for integrating the quality development, quality maintenance and quality improvement efforts of the various groups in an organization so as to enable production and service at the most economical levels which allow for full customers and satisfaction.” In addition W.E Deming states that quality should start by the top management, and J.M. Juran pointed out that motivation and involvement are associated with quality improvement. Following these three researchers, other authors have developed the conception of TQM. TQM does help improve the development of the company but it is important to consider the way in which the technique is implemented. With this means a supportive environment of: * Supportive infrastructure * Appropiate leadership ...
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...3) What general obstacles would you foresee in a company such as Ivanovskaya Manufactura trying to make the transition from a hierarchical, or bureaucratic, to a learning organization? What are some general measures managers can take to smooth the way? The main benefits are; * Maintaining levels of innovation and remaining competitive[9] * Being better placed to respond to external pressures[9] * Having the knowledge to better link resources to customer needs[1] * Improving quality of outputs at all levels[1] * Improving Corporate image by becoming more people oriented[1] Increasing the pace of change within the organization[1] However there are of course some obstacles that the company will have to tackle in order to successfully transition from a hierarcgial to a learning organization, such as Even within or without learning organization, problems can stall the process of learning or cause it to regress. Most of them arise from an organization not fully embracing all the necessary facets. Once these problems can be identified, work can begin on improving them. Some organizations find it hard to embrace personal mastery because as a concept it is intangible and the benefits cannot be quantified;,[3] personal mastery can even be seen as a threat to the organization. This threat can be real, as Senge[3] points out, that “to empower people in an unaligned organization can be counterproductive”. In other words, if individuals do not engage with...
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...Final Organizational QI Plan Hani Mortada HCS 588 October 7, 2013 Ronald Konnick Final Organizational QI Plan Executive Summary The concept of using computer technology to improve the management of patient information is not new. Research into the implementation of health care information systems spans more than thirty years at a cost of millions of dollars (Zheng, McGrath, Hamilton, Tanner, White, Pohl, 2009). In spite of those costly efforts, patient records continue to be primarily paper-based. The Institute of Medicine (IOM) (1991) of the National Academy of Sciences recognized the magnitude of the problems associated with paper medical records systems and called for the adoption of computer-based patient records (CPR) or electronic medical records (EMR) as the standard for all patient records by the year 2001. EMR systems have been shown to have value in patient care; they are not widely used by clinicians in community-based practice. Although there are barriers to the productive use of EMR systems in primary care and there are situations in which such systems have failed, there are early adopters of this technology who have successfully implemented the systems and made them an integral part of their organizations. Gaining better understanding of the usefulness of EMR systems and how they might be broadly utilized...
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...health outcomes and are consistent with current professional knowledge (Chassin, 2006). According to the Institute of Medicine, To Err Is Human, the majority of medical errors result from defective systems and procedures, not individuals. Processes that are ineffective and flexible, changing case mix of patients, health insurance, differences in provider education and experience, and numerous other factors contribute to the difficulty of health care. With this in mind, today’s health care industry functions at a lower level than it can and should, and it put forth the following six aims of health care: effective, safe, patient-centered, timely, efficient, and equitable (Ferlie, 2005). The aims of effectiveness and safety are targeted through various processes that will measure whether providers of health care perform processes that have been demonstrated to achieve the desired aims and avoid those processes that are given toward maltreatment. The goals of measuring health care quality are to determine the effects of health care on desired outcomes and to assess the degree to which health care follows the process based on scientific evidence or agreed to by professional cooperation and is constant with patient inclinations (Horn, Hickey, & Carrol, 2002). Because errors are caused by system or procedure failures, it is...
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...2011 download.benjaminsommer.com Benjamin Sommer [SOFTWARE ENGINEERING LECTURE NOTES] Brief and detailed notes from lectures held at the Ludwig-Maximilian-University, Faculty of Computer Science in Germany. This document neither claims completeness, nor correctness of the presented topic. Please let me know in case of errors or missing information: contact.benjaminsommer.com [SOFTWARE ENGINEERING LECTURE NOTES] October 21, 2011 OVERVIEW SOFTWARE PROCESSES SOFTWARE PROCESS MODELS PROCESS ACTIVITIES COPING WITH CHANGE THE RATIONAL UNIFIED PROCESS AGILE SOFTWARE DEVELOPMENT AGILE METHODS PLAN-DRIVEN AND AGILE DEVELOPMENT EXTREME PROGRAMMING AGILE PROJECT MANAGEMENT SCALING AGILE METHODS REQUIREMENTS ENGINEERING FUNCTIONAL AND NON-FUNCTIONAL REQUIREMENTS THE SOFTWARE REQUIREMENTS DOCUMENT REQUIREMENTS SPECIFICATION REQUIREMENTS ENGINEERING PROCESSES REQUIREMENTS ELICITATION AND ANALYSIS REQUIREMENTS VALIDATION REQUIREMENTS MANAGEMENT SYSTEM MODELING CONTEXT MODELS INTERACTION MODELS STRUCTURAL MODELS BEHAVIORAL MODELS MODEL-DRIVEN ENGINEERING ARCHITECTURAL DESIGN ARCHITECTURAL DESIGN DECISIONS ARCHITECTURAL VIEWS ARCHITECTURAL PATTERNS APPLICATION ARCHITECTURES DESIGN AND IMPLEMENTATION OBJECT-ORIENTED DESIGN USING THE UML DESIGN PATTERNS IMPLEMENTATION ISSUES OPEN SOURCE DEVELOPMENT SOFTWARE TESTING DEVELOPMENT TESTING TEST-DRIVEN DEVELOPMENT RELEASE TESTING download.benjaminsommer.com | 1 3 5 5 7 10 13 16 16 17 17 19 20 21 21 23 24 25 26 29 30 31 32 32 33 34 35 37 38 39...
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...understand the reason for the occurrence of an event (McEwen & Willis, 2014, p. 413). In different clinical settings, nurses care for patients amidst all the interruption and distraction and therefore are prone to making medical errors despite their best intentions. Medical errors are common in most healthcare settings and more so in the critical care units. According to the 1999 Institute of Medicine (IOM) report, several thousand people die each year from avoidable medical errors. Medical errors have been defined in different ways by various authors but one that captures the essence of this problem is that contained in the IOM report of 1999 which described this issue as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (IOM, 1999). Medical errors include but are not limited to medication errors, errors associated with medical and surgical procedures, those associated with transcription and charting activities, adverse drug events, restraint-related injuries, or mistaken identities and are more likely to occur in the emergency room, operating room and critical care units (IOM, 1999; Rogers, Dean, Hwang & Scott, 2008). The purpose of this paper is to address the serious problem of medical errors in healthcare in general and specifically the techniques critical care nurses employ to identify, correct and/or interrupt such problems (Henneman, Gawlinski, Blank, Hennema, Jordan & McKenzie,...
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...Sigma projects include the following EXCEPT: (Points : 5) financial return. impacts on customers and organizational effectiveness. @ fit to existing government legislation(s) on quality. probability of success. Question 3.3. (TCO C) Lean production refers to approaches that originated at: (Points : 5) @ Ford. Xerox. Motorola. Toyota. Question 4.4. (TCO C) Which one of the following is NOT one of the three levels of mistake-proofing? (Points : 5) Designing potential errors out of the process. Identifying potential defects and stopping a process before the defect is produced. @ Training the workforce in implementing and monitoring the modified process. Finding defects that enter or leave a process. Question 5.5. (TCO B) _____ measures are generally tracked by senior leadership to gauge overall organizational performance. (Points : 5) @ Financial Customer Product Service Question 6.6. (TCO I) The cost associated with unplanned machine downtime, when operators halt the production line after identifying an unacceptably high rate of defective output, should be classified as: (Points : 5) a prevention cost. an internal quality cost. @ an internal failure cost. a reactive failure cost. Question 7.7. (TCO A) Which of the following is NOT a characteristic of a...
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...------------------------------------------------- * ------------------------------------------------- 1. (TCO B) Some believe that a project management office (PMO) is nothing more than yet another level of management with the associated added cost and bureaucracy. Project Management experts tell us that this is a good thing. Which of these points of view is correct, and how do you (in your own words, though you may cite your readings to support your view as necessary) justify your conclusion? Remember that business thinks primarily in terms of dollars and benefit/cost ratios. (Points : 20) 2. (TCO B) One of the most traumatic decisions a project manager must sometimes make is to cancel a project. In an article titled "How to Fail In Project Management without Really Trying," Business Horizons Reprint No. BH010, the following (whimsical but true) reasons that projects go out of control were identified: 1. Ignore the project environment, including stakeholders 2. Push a new technology to market too quickly 3. Don't bother building fallback positions 4. When problems occur, shoot the one most visible 5. Let new ideas starve to death from inertia 6. Don't bother conducting feasibility studies 7. Never admit a project is a failure 8. Over-manage project managers and their teams 9. Never, never conduct post-failure reviews 10. Never bother to understand project trade-offs 11. Allow political expediency and infighting to dictate crucial project decisions 12. Make sure the project is run by a weak leader ...
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...OrganizationaL Development Considerable changes occurs when an organization make compensation for errors within its overall strategy for achievements or make any modification to its existing operations. The purpose of this paper is to study the broad principles of organizational development, explain the process of organizational development, identify the theories associated with organizational development and describe the conditions necessary for successful organizational change and development. “Organizational development is a set of behavioral science–based theories, values, strategies, and technologies aimed at planned change of the organizational work setting for the purpose of enhancing individual development and improving organizational performance, through the alteration of organizational members’ on-the-job behaviors’’ (Porras & Robertson, 1992). Process of Organizational Development Organizational development is a process by which organizations use the theories and technology of the behavioral sciences to facilitate changes that enhance their effectiveness (Jex & Britt, 2008). According to an article found in The Resource Behind Human Resources website, the OD Process is based on the action research model that begins with an identified problem or need for change. The process proceeds through assessment, planning of an intervention, implementing the intervention, gathering data to evaluate the intervention, and determining if satisfactory progress has been made...
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...likely to give it an external attribution. If not we will probably judge the behaviour to be internal. 2. Consensus: behaviour shows consensus when everyone who faces a similar situation responds in the same way. If consensus is high you will probably give an external attribution to the individual’s behaviour whereas if the consensus is low it will be attributed to an internal cause. 3. Consistency: does the person respond the say way over time? The more consistent the behaviour is the more we are inclined to attribute it to internal factors. Errors and bias that distort attribution: Fundamental attribution error: the tendency to underestimate the influence of external factors and overestimate the influence of internal factors when making judgements about the behaviour of others. Self-serving bias: the tendency for individuals to attribute their own successes to internal factors and put the blame for failures on external...
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...the book, experimental innovators are not rigid in pursuit of their first ideas and preserve through many failures and move on quickly. In approaching their challenging goals, they accept the fact that they will face many unpredictable obstacles, risks and even breakdowns which they have to cope with and overcome without considerable emotional impacts. These characteristics of experimental innovators are results of having a growth mind-set. People with this mind-set are always willing to grow hence more open to accept new challenges and risks. They do not seek validation of others after every performance, and do not believe that their failures reflect their capabilities and do not get disappointed by them. As a result, they do not stop trying new things until they gain major accomplishments. On the other hand, people with fixed mind-sets avoid taking new challenges because they are afraid of the possible failures. Any negative comment, failure, or bad performance tends to destroy their self-image; consequently, their main concern becomes seeking validation of others by trying to look smart and successful. They place so much emphasis on minimizing risks and errors that they keep doing things they are already good at instead of trying new things. As a result, they plateau early and achieve less than their full potential. We are programmed at an early age to think that failure is bad. That belief puts off organizations from effectively learning from their missteps. (Amy C. Edmondson...
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