Queensland Health Case Study AnalysisQueensland Health Crisis

1) What factors might be affecting the job performance of clinicians at Queensland Health?

There are varied approaches to responding to this question (noting that the question does not ask for suggestions on improving performance), since it is recognised that there is an interconnectedness between individuals, the teams/groups with which they associate and the additional requirements of organisation. Organisations themselves are sometimes referred to as open systems which transform human and physical resources received (a transformation process) from their environment into goods and services that are then returned to the environment. The organisation’s requirements to engage with external stakeholders through alliances or partnerships, then further connects the performance of individuals to the requirements of the external environment. Owing to this interconnectedness, job performance can thus be influenced at the level of individuals (influences such as personality, motivation, expectancy and cultural background), groups/teams (influences such as team roles, communication, group size, equity, task, cohesion and management approaches), organisational structure and culture and the external environment (such as demands by markets, alliance partners). With this in mind and for the sake of simplicity, the discussion will begin with reference to a job performance equation (1) and will focus ostensibly on the job performance at the individual level (the clinicians). Subsequent questions in this examination, consider interventionist strategies that impinge on performance.

Job performance = attributes x work effort x organisational support (1)

Considering each variable in the equation in context of the information provided in the case study, the Job performance of clinicians is better understood:

Attributes: Clinicians see themselves as dedicated, professional and committed to providing the best

possible care for patients and other customers (info from internal review) Culture of bullying and intimidation from upper management on those who seek to point

out problems, ask for money to help department Too much paperwork, where admin staff works 9 am-5pm hospital hours, while clinicians

may be required to attend to patients 24 hours/day - so clinicians are required to carry the administrative overload in the off hours rather than concertedly practicing medicine.

Worked long hours with clinician staff shortages , feelings of being underpaid with little access for professional development (to improve health care)

Some clinicians are from countries with different standards and education levels, which potentially compromises the system as good clinicians sometimes take on increased workloads to cover deficiencies.

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Work Effort: In the off hours (outside of 9am to 5 pm) clinicians often take on excessive

administrative duties to cover for administration staff who work conventional hours. This requirements appears to be consistent with the organisational norm – which is to meet budgetary requirements and so in the process, clinicians inadvertently are required to take on task that might often fall outside of the role that they are primarily employed to do.

Clinicians have to deal with more patients than is reported, owing to the culture of secrecy where waiting list statistics have been hidden form public scrutiny under the justification of patient confidentiality. The review estimated that in fact almost 110000 people were waiting for a consultation with a specialist is a public hospital and that about 25000 of those would actually require surgery.

Possibly have to cover and help those clinicians from other countries that may not have the skill set, knowledge, or experience to be able to practice in Australia to the level of care expected.

Limited resources have clinicians engaging with networks across jurisdictions to ensure that levels of patient care are upheld where possible.

Organisational Support: From the top down the focus of the organisation is on budget, even if it means possibly

distorting the true position of the organisation. Clinician’s complaining are faced with intimidation and bullying. There is a complete lack of support from the organisation from the top down, with

everyone just watching their own back, while making sure that political agendas are represented.

The culture is entrenched since this has transgressed a number of successive governments.

The factors outlined thus far tend to exacerbate lower job performance and stress, which often culminates in burn out, sick days, stress, and poor retention. While many of the staff may have the attributes required to generate the performance required, this case suggests that work effort (leading to burnout) and organisational support (which undermines performance) are the biggest issues in terms of work performance. The culture portrayed would be adversely affecting clinician motivation levels and therefore their willingness to perform. Also the case suggests that the opportunity to perform is not necessarily given to all staff members due to poor job design and a destructive culture.

Work effort is directly related to the motivation levels of staff which were not helped by the centralised decision making culture at Qld Health . Presumably, this has meant that clinicians have little influence over decisions which directly affect them, including the need to have to pick up the administrative slack. Page 2

Further, job performance requires value congruence between clinician and organisation. This apparent absence is a source of cognitive dissonance, which will further deter job performance. Values after all, create attitudes that predisposes behaviour, including job engagement.

Beliefs and values Attitudes Behaviour Create that predispose

The lack of organisational commitment, will negate Job Satisfaction and lower job performance

Ultimately, high levels of motivation will lead towards improved job performances. Although needs theories of motivation are not always supported empirically (such as Maslow), Herberg’s two factor theory, which has mixed empirical support, can explain job performance of clinicians as it pertains to the current case study. Focussing on hygiene factors (can either satisfy or dissatisfy workers), it is evident that there are a number of hygiene factors that are leading towards job dissatisfaction and therefore undermining job performance. Leading to levels of often extreme dissatisfaction are factors such as relationship (supervisory/management), peers (having to take on increased workloads at times associated with lower trained foreign clinicians), work conditions and company policy/administration (requirements of additional administrative duties and having to endure culture of bullying, etc). While these factors are by no means exhaustive, they lend weight towards diminishing job performance.

Further, in considering process theory (Goal setting and vroom expectancy theory) further facets that may elude to deteriorating job performance are exposed. Goal setting requires some expectation that task effort will lead to task performance. Since clinicians are often excluded from managerial decisions, it can only be assumed that participation in task efforts are compromised. With feedback probably largely being directed towards budgetary targets, performance is further compromised. The expectation that clinicians are required to do more with less might also deteriorate task performance since goals will be become difficult to achieve. Vroom’s expectancy theory also highlights the possible uncoupling of effort to performance (E-F) and performance to outcomes (P-O). The E-F expectancy is undermined by a lack of trained employees, selection of people with required competencies (eg foreign poorly trained doctors), lack of role clarification (clinicians becoming administrators), insufficient resources and insufficient feedback. P-O outcomes are compromised with budgetary performance indicators being possibly more valued than patient care outcomes.

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Lastly, the organisation is a large politiciced beauracracy. The Theory X practices adopted by management is not inclusive of the participation and empowerment of clinicians that is required for them to achieve high performance. This, coupled with inappropriate organisational support (including structure and culture), excessive workloads, incongruence of values, the motivational dissatisfiers and curtailment of motivating factors – are all factors that appear to be adversely effecting the job performance of clinicians at Queensland Health.

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2. What shared values, beliefs and behaviours have impacted upon Queensland Health’s culture? What steps would you suggest to improve the culture?

To analyse the culture a first step would to be use Cultural Web.

Cultural Web can be used to understand the current culture and its issues.

Stories: Hiring of Jayant Patel a surgeon who had lost his US licence to practice medicine but being able

to practice medicine in Australia. There were many people trying to report their concerns based on his behaviour but nothing was done.

The practice of suppression, in which he claimed at least one former health minister has been instrumental, had encouraged Queensland Health staff to act in a similar fashion

Underperforming staff not dealt with or being promoted

Rituals and Routines: over-bureaucratise, secrecy, bullying and intimidation, from top down. ‘History of a culture of concealment within and pertaining to Queensland Health’ due to

inherited behaviour from former health minister. Claims of patient confidentiality to cover discrepancies on true size of waiting lists, etc. To

continue the false idea and thought the health system was doing fine and on budget, that there were no problems.

Look after yourself/department (every man for themselves)

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Control System: Executive Director of Health Services is responsible for 80% of Queensland Health’s resources.

Minister of Health is the ultimate leader of the organisation. The core value of the organisation was ‘the budget’ and it was used as a control system. The

Government. The use of one person who was in charge of 80% of the resources for the whole organisation. They decided who and where those resources would be allocated.

Hierarchical decision process Non-collaborative No accountability

Organisational structures: Classical class structure made up of support staff, nurses, clinicians, specialists, admin,

managers; augmented by top class structure of executive, and government. Bureaucratic funnelled up to three zones and a central office Executive Director of Health Services – control 80% of resources Minister of Health – the top. Lack of cooperation, trust between teams - ‘Silos’ Managers out of touch with needs of front line staff

Power Structures: 80% resources controlled by Executive Director of Health Services. “If I am at the director-

general level and the ministerial staff want to vet and read the newsletters I wasn’t to send to my staff, in the end I just lose interest in sending newsletters to my staff.

Reluctance to share information across silos. Managers did not encourage-staff participation in problem solving, did not engage with staff and

did not properly manage non-performing staff. Failure of leaders, managers and supervisors of dealing with complex problems, did not engage

their staff, did not properly manage non-performing staff Ministerial staff needs to vet internal newsletter from Director to hospital staff. Budget integrity centred managers at a modest level that there’s not much point asking for

more money and not much point raising the problem, self-regulating power negative.

Symbols: bureaucracy, government, and the symbolic roles of doctors, nurses, specialists, support staff

This cultural web is a good way to break apart all of the facets of the problem but to tackle these issues but looking on how to improve the overall culture you first see that: in Tuckman’s group dynamics.

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Within Queensland health is supported by three zones and a central corporate office. These hierarchical layers of decision making did not support a responsive and efficient health system. The centralised and hierarchical structure contributed to the frustration of staff and customers (patients and others). Many Staff felt angry, frustrated and resentful towards senior managers and some reported experiencing bullying and intimidation when seeking more funding to deliver patient care. The report showed ‘an entrenched and negative culture of bullying, threat, intimidation, coercion and retribution on the one hand and of secrecy, blaming and avoiding responsibility on the other. This culture is in no doubt one of the reasons surgeon Jayant Patel had not been dealt with earlier by management even though there were concerns reported to by the staff. This level of secrecy enforced all the way down from the ministry in hiding the real numbers of wait times, surgeries, etc. Reinforced this culture of non-reporting and no accountability.

In the below two diagrams it appears that the culture in the Healthcare system specifically the patient facing ones are continually stuck and repeating the storming section. The culture just doesn’t build cohesion.

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To start you need to break the cycle of bullying, secrecy and intimidation. You need to empower those who know something is wrong and give them a voice and place to do so. You need to increase protection of those people who choose to make their concerns public (whistleblowers) and you need to create a separate central body to oversee public interest disclosures. These were already recommended to the government but the premier Peter Beattie rejected the suggestions. The culture has to change all the way at the top in the government and they also have to be held responsible. There needs to be a change to the overall reporting structure in the organisation, create a flatter structure. Give departments , and clinicians more autonomy over budget within certain guidelines.

For example if a clinician rules that a MRI or catscan is warranted maybe there are 7 criteria that would allow this to happen without any okay, that they have to sign off and be responsible. That they may be only to have a certain amount of quota per month based on those criteria and if either the criteria isn’t met or they are the over their quota then there direct supervisor would have to approve and be responsible. They may have a certain amount of quota or guidelines on top, but it would help put context to those incidents of over budget and also give responsibility back to those on the front lines that have to make split decisions in regards to care, but also at least be budget conscious.

This example is a good place to get input from all aspects of the group who would be involved in the decision process and may come up with better guidelines or processes that in turn give them more empowerment, motivation and job satisfaction. It has already been said that staff are all dedicated to giving the best possible care to patients, so they should allow them to do so within reason and balance.

By using the below process:

The Business Control Process

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As the organisations flattens out and allows the shift from being budget driven and hiding the numbers, that you allow the truth to come out, and allow those in the trenches to help develop and empowered to change happen. That this process is continuous and if the ultimate goal is for better health care with conservative views in regards to the budget, as long as you include the different departments in the change it will help.

Job enrichment (pg 162) Herzberg’s principles of job enrichmentPrinciple Motivators involved

1. Remove some control while retaining accountability

Responsibility and Achievement

2. Increase the accountability of individuals for their own work

Responsibility and recognition

3. Give a person a complete natural unit of work (module, division, area and so on

Responsibility, achievement and recognition

4. Grant additional authority to employees in their activities

Responsibility, achievement and recognition

5. Make periodic reports directly available to the worker rather than to the supervisor

Recognition

6. Introduce new and more difficult tasks that the individual has not previously handled

Growth and learning

7. Assign to individuals specific or Responsibility, achievement ,recognition and

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specialised tasks; enable them to become experts

advancement

On a smaller scale you would also have to address the culture of leaders, managers and supervisors often failed to deal with complex situations, encourage staff participation in problem solving, did not engage with staff and did not properly manage non-performing staff. To do this managers have to be taught that its their responsibility to do these things and maybe start instituting KPI’s (Key Performance indicators). That after a difficult case they should debrief the staff involved and look at ways they could improved on the case even it was good or bad. That allowing the staff to learn from this only increases their job satisfaction and motivation for the next case to come through. Also when dealing with non-performing staff it gives the manager a chance to help improve their skills (if it’s a confidence thing), or identify missing skills (need more training). If you showing an interest in all staff this only improves group cohesion, motivation, job satisfaction, decreases stress, increases retention especially if your the teaching them new skills, increasing their knowledge base. All of these items discussed increases various motivators that will only improve the overall culture within the group.

Sample core job characteristics for enriched and un-enriched jobs:

Enriched Un-enrichedSkill Variety Decided own strategy for

performing task and changed strategy at will

Were provided with explicit instructions for task to perform and strategy to use (e.g. ‘first, open letter)

Task Identity Formed into groups of ten; performed all necessary operations on a certain proportion of customer requests

As an individual, performed just one of these operations on all requests

Autonomy Chose length and timing of breaks. Performed own inspections at intervals they determined

Except for breaks, stayed at workplace throughout the day. Had work periodically checked by inspectors

Feedback Saw productive posted on scoreboards at end of each day

Received no specific information about performance level

When looking at the current jobs if they are either enriched or un-enriched Skill variety – is more un-enriched from the very top of directors who can’t release internal memos without government scrutiny and so doesn’t send any internal information anymore. All the way to clinicians who are driven by maintaining budget constraints and hiding proper statistics of actual wait

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times, surgery, etc and are bogged down by the sheer mountain of admin stuff without the proper support or time.

Autonomy – Un-enriched – again fro decision making taken away up to the top, as well as pressure from government body overseeing critical decisions. Core value of the system is ‘budget constraint’ which has shaped the entrenched culture. People are not free to make the right decision for the good of the patient for fear of being bullied, threatened, etc.

Feedback – Un-enriched – There is no feedback with in a culture of ‘secrecy, bullying, intimidation, etc’. No one treats the concerns for improper care let alone praising good care.

Another item to break the culture after flattening out is to increase cross-communication and the most important aspect of cultural change would be to build trust between the people making up the multi-disciplinary teams that are integral to providing healthcare services. The report said the culture could only improve, if there was participation in team problem solving, a redesign of the workplace, systems improvement and a focus on the patient when making decisions about care.

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Question 3

In order to sustain an engaged and productive workforce, apart from cultural intervention, what other processes could Queensland Health employ? Make recommendations for alternative interventions. Use relevant OB theory to support recommendations.

In order to sustain an engaged and productive workforce you need to address certain aspects about the job without specifically looking at the culture.

Job Satisfaction is the degree to which an individual feels positively or negatively about work. Two factors strongly related to job satisfaction are organisational commitment and Job involvement. The culture at Qld Health makes both of these attitudes hard to achieve. Firstly, staff are not involved in the decision making process and have felt anger, frustration and resentful to managers. Staff could be described as having an External locus of control – people feeling as though what happens to them is out of their control. There also seems to be evidence of Machiavellianism of managers who manipulate others purely for personal gain to meet budget or avoid reprimand.The case talks about ‘silos’ built around occupational groups and a distinct lack of trust or teamwork. It is hard for an employee to feel part of an organisation which has this type of culture, when there is lack of information sharing around the organisation which reinforces those negative aspects of the organisation, and is continued to be reinforced of workload and budget constraints.

Meglino Framework decribes four values those are especially important in the workplace. Achievement Helping and concern for others Honesty Fairness

Staff values were not considered. Report (done by the healthcare system) found in general personnel were dedicated, professional and committed to providing the best possible care for patients. It suggests that majority of staff have values described by Meglino and were being neglected by the Qld Health management. Without acceptable levels of Job Satisfaction there is not going to be sufficient work effort and thus job performance will be reduced. This can result in absenteeism, high turnover, low morale and stress as has been seen in the case.

Within the top nine work-related values (D Jamieson and J O’Mara, Managing workforce) these appear to be the most effect by the current situations.

1. Recognition for competence and accomplishments2. Respect and dignity3. Personal choice and freedom

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4. Involvement at work5. Pride in one’s work8. Self-development

One aspect to look at is job design in itself:

Job designThe four basic approaches to job design (simplification, enlargement and rotation, and enrichment) have provided vital insights into the complexity of effective job design. Collectively, they are an important platform for later theorists. However, the common factor underlying these approaches is that they are ‘static’; that is, they assume that all individuals will respond in the same, positive manner to these approaches. They fail to recognise the ‘dynamic’ nature of individual behaviour – which workers can, and will respond in a variety of ways to the implementation of any innovative job design approach.

The job characteristics model

1. Skill variety - the degree to which the job requires an employee to undertake a variety of different activities and use different skills and talents

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2. Task identity – the degree to which the job requires completion of a ‘whole’ and identifiable piece of work (that is, it involves doing a job from beginning to end with a visible outcome)

3. Task significance – the degree to which the job is important and involves a meaningful contribution to the organisation or society in general

4. Autonomy – the degree to which the job gives the employee substantial freedom, independence and discretion in scheduling the work and determining the procedures used in carrying it out.

5. Job feedback – the degree to which carrying out the work activities results in the employee obtaining direct and clear information on how well the job has been done.

Critical psychological states: Experienced meaningfulness in the work Experienced responsibility for the outcomes of the work Knowledge of actual results of the work activities

These are important in job retention of employees who could be overstressed, overworked, etc.

Moderators are: job-design moderators Growth-need strength – the degree to which a person desires the opportunity for self-direction,

learning and personal accomplishment at work. It’s similar to Maslow’s esteem and self-actualisation and Alderfer’s growth needs. If doctors were to conduct a debriefing after hard successful or unsuccessful cases this would help all those involved to grow.

Knowledge and skill: needed for performance in an enriched job are predicted to respond positively to enrichment. The debriefing further helps with were to teach new skills, reinforce old skills or those who are lacking more training. It also re-enforces with those the good job that they are doing.

Context satisfaction: extent of how much a employee is satisfied with salary levels, supervision and working conditions. These de-briefings are good indicators for all involved on the job that they are doing. It lets them know over the whole context of their job satisfaction.

The organisation is going to have get more clinical staff and they should provide more flexible and family-friendly work arrangements, fair remuneration, and ongoing opportunities for professional developments. For example:

For admin staff and even nurses you could have them work 9am to 9pm shifts and only work 3 days on and three days off, rotation schedule to make sure that the administration work for the doctors is being done and they can practice medicine. It is a longer shift but they get more time off and so in turn more time to spend with their kids. This might appeal to some who then would could have cut down on daycare costs if they have a partner, as they would have fewer days working but the same hours. Also nurses might be inclined to this as it would also give them more time with their family while also maximizing their times with patients and minimize anything missed in shift swapping.

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Doctors you might do three shifts of 7am to 3pm, 3pm to 11pm and 11pm to 7 am. At all of those shifts you would still get the opportunity to spend time with your family, and they would rotate this. This is one example of a flexible work arrangement that many people are striving for a work balance lifestyle.

You can also institute Job rotation, for example, a nurse may be rotated on a monthly basis, looking after geriatric patients one month, surgical patients the next and rehabilitation patients each third month.While job rotation may decrease efficiency because people spend more time changing, it can add to workforce flexibility. Staff can be moved from one job to another. This is often the primary purpose of job rotation. Vertical loading is a key aspect of job enrichment.

To help sustain an engaged and productive workforce you should first follow the steps for leadership change. I would first separate the reporting structure and have someone who is not elected at the top, can be still accountable from the government standpoint but the minister of health can’t be the leader as there are political and other factors to his decisions that having nothing to do with the welfare of the healthcare system. This follows the Steps for Leadership Change from Kotter (2002). 1. Establish a sense of urgency2. Create a guiding coalition3. Develop a vision and strategy4. Communicate the change Vision5. Empower broad-based action6. Create short-term wins7. Consolidate gains and produce more change8. Anchor new approaches in the culture

If we look at A Typology of Change strategies from Dexter Dunphy & Doug Stace (1990) we can consider the strategy which best fits for Qld Health. They require a transformational over an incremental change. There is support for change within the organisation and collaboration will be vital to changing the culture and implanting successful strategies. However due to the urgency caused by the anger and fear of bullied employees a more directive/coercive mode made be required. For these reasons Qld Health really need a combination of a Charismatic transformation and Dictatorial Transformation.

Incremental Change Strategies Transformative Change Strategies

Collaborative/Consultative modes

1. Participative evolutionUse when organisation is in fit but needs minor adjustment, or is out of fit but time is available and key interest groups favour

2. Charismatic transformation

Use when organisation is out of fit, there is little time for extensive participation but

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change. there is support for radical change with the organisation.

Directive / coercive modes 3. Forced evolutionUse when organisation is in fit but needs minor adjustment, or is out of fit but time is available, but key interest groups oppose change

4. Dictatorial transformation

Use when organisation is out of fit, there is not time for extensive participation and no support within the organisation for radical change, but radical change is vital to organisational survival and fulfilment of basic mission

From this case as a public sector organisation with many undercurrent and entrenched ideals you will need to use a combination of a charismatic transformation as well as Dictatorial transformation. The first is because with the organisations track record you will need to get everyone involved in the change to effectively re-build back trust, and there is support for radical change. You need the Dictatorial transformation because there will be great resistance from those who are comfortable with the status quo and you will need to change that or you will lose all credibility with those who are in support of the change.

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With the organisation is in such disarray you would start in step 1: with comments about QLD Health. Establish a sense of urgency

a. Core Challenge: Get people out of the bunker and ready to move. This means that the whole organisation has to be shaken up that change is coming and they need to be on board

b. Desired New Behaviour: People start telling each other "Lets go, we need to change things." That there is an increase from all levels of the Health care system change is underway, their is an increase in energy and motivation to change.

Step 2 Create a guiding coalitionb. Core challenge: get the right people in place with the trust, emotional commitment and

teamwork to guide a very difficult change process. You would need to build this and include everyone from nurse manager, biomedical engineers, doctors, janitorial, everyone with a vested interest in the whole process (the best ideas come from the least expected source)

c. Desired new behaviour: a group powerful enough to guide large change that works well together (creating solid cross departmental and organised groups is important to create cohesion and respect across the organisation.) If it seen throughout that everyone has a voice, and is treated equal, then that attitude will help to spread through the organisation

Step 3 Develop a vision and strategyc. Core Challenge: Get the guiding team to create the right vision and strategies to guide

action in all of the remaining stages of change. This requires moving beyond number

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crunching to address the creative and emotional components of vision (make sure that budget isn’t the focus but better healthcare, although you can’t discount budget conservatism in light of the GFC)

d. Desired New Behaviour: The guiding team develops the right vision and strategy for the change effort – very important as this will continue to have increase scrutiny from all members of the organisation and to help with buy in to the change.

5. Communicate the change Visiond. Core Challenge: Get as many people as possible acting to make the vision a realitye. Desired New Behaviour: People begin to buy into the change and this shows in their

behaviour6. Empower broad-based action

e. Core Challenge: Remove key obstacles that stop people from acting on the visionf. Desired New Behaviour: More people feel able to act, and do act, on the vision

7. Create short-term winsf. Core Challenge: Produce enough short-term wins fast enough to energise the change

helpers, enlighten the pessimists, defuse the cynics and build momentum for the effortg. Desired New Behaviour: Momentum builds as people try to fulfil the vision while fewer

and fewer resist change.8. Consolidate gains and produce more change

g. Core Challenge: Continue with wave after wave of change, not stopping until the vision is a reality - no matter how big the obstacles

h. Desired New Behaviour: People remain energised and motivated to push change forward until the vision is fulfilled

9. Anchor new approaches in the cultureh. Core Challenge: Create a supporting structure that provides roots for the new ways of

operatingi. Desired New Behaviour: New and winning behaviour continues despite the pull of

tradition turnover of change leaders, etc.

Recommendations would be for an a head of the healthcare that would not have 80% control over available resources that that control would be released incrementally down. That there would be guidelines and budget amounts per area in the healthcare. That doctors would have the autonomy to make decisions about tests, care, treatment if certain criteria is met, and if not then it would be up to their superior, with the same scrutiny. That the budget would be relaxed but still critically watched to see where adjustments have to be made and where it went over, those who are responsible held accountable to provide the context to the over amount.

That these changes to the budget control, decision making has to be looked at with The Business Control Process

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1) That the standard is set2) You measure the output (check to see the budget, usage of resources across organisation)3) Compare budget across organisation, compare resource use (MRI, catscan, surgery, etc)4) See where adjustments need to make with consideration of context5) Either the standard changes to accommodate, outputs get changed or everything remains status

quoThe point to this process that it is a ongoing process that is monitored by the top (without government involvement) and then reviewed by independent review board that then reports findings to the government and the top level of the Healthcare Group, to keep it honest, true and correct.

There also has to be an Obusbudman who would deal with complaints from outside the organisation (patients) as well as confidentiality of internal staff, they would have the autonomy to investigate and then report t their findings and what the organisation should do.

They should also be doing research on what patients feel about their care when they stay in the hospital. Everything from cleanliness, admin staff (checking in), to nurses, doctors, etc. This gives a snapshot from the patients’ eyes what areas that may be perceived performing well but in the eyes of the patient not performing well at all. This would be an independent review and could be used to point out areas within the job criteria or the overall process and strategies that need improvement.

As discussed earlier debriefings are important after all types of cases and were earlier discussed.

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