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    Section B 01 Session 16

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    Hardik Sharma
    The document summarizes events at the Bristol Royal Infirmary (BRI) pediatric cardiac surgery unit from 1984 to 2001. [1] Mortality rates at BRI for pediatric cardiac surgery were double other centers. [2] Repeated complaints were raised about quality but dismissed by leadership. [3] A public inquiry from 1996-2001 found systemic failures in leadership, oversight and a "muddling through" mindset that prioritized reputation over patient safety.

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    Section B 01 Session 16

    Uploaded by

    Hardik Sharma
    21 views9 pages
    The document summarizes events at the Bristol Royal Infirmary (BRI) pediatric cardiac surgery unit from 1984 to 2001. [1] Mortality rates at BRI for pediatric cardiac surgery were double other centers. [2] Repeated complaints were raised about quality but dismissed by leadership. [3] A public inquiry from 1996-2001 found systemic failures in leadership, oversight and a "muddling through" mindset that prioritized reputation over patient safety.

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    Section_B_01_Session_16

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    The document summarizes events at the Bristol Royal Infirmary (BRI) pediatric cardiac surgery unit from 1984 to 2001. [1] Mortality rates at BRI for pediatric cardiac surgery were double other centers. [2] Repeated complaints were raised about quality but dismissed by leadership. [3] A public inquiry from 1996-2001 found systemic failures in leadership, oversight and a "muddling through" mindset that prioritized reputation over patient safety.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    21 views9 pages

    Section B 01 Session 16

    Uploaded by

    Hardik Sharma
    The document summarizes events at the Bristol Royal Infirmary (BRI) pediatric cardiac surgery unit from 1984 to 2001. [1] Mortality rates at BRI for pediatric cardiac surgery were double other centers. [2] Repeated complaints were raised about quality but dismissed by leadership. [3] A public inquiry from 1996-2001 found systemic failures in leadership, oversight and a "muddling through" mindset that prioritized reputation over patient safety.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 9

    Hospitals as Cultures of

    Entrapment
    Aashi Jain - 2111003
    Aman Jauhri - 2111032
    Amar Baroni - 2111033
    Bommidi Sharath Chandra - 2111068
    Nallakunta Sai Sumanth - 2111188
    Ujjwal Butalia - 2111307
    Safety Culture and Cultural blind spots
    Safety culture is the set of assumptions and practices
    necessary for healthcare organizations to provide optimal
    care

    But these can also be a source of danger if they blind factors


    important to performance leading an organization down the
    wrong path with dire consequences
    Description of events at BRI
    ➢ In 1984, BRI and BCH were designated as one of the nine SRS centres
    ➢ BRI was not doing well in the area of pediatric heart surgery
    ➢ 1986, professor at the University of Wales Wrote about bad quality of
    surgery
    ➢ About 100 formal concerns about quality were raised by a consultant
    ➢ Article on post mortem report emerged in 1989
    ➢ 1991, Royal College of Physicians refused to accreddit the BRHSC as an
    institution to train pediatric cardiology
    ➢ 1996(inquiry called) - 1998(inquiry started) - 2001(report published)
    Description of events at BRI
    ➢ Mortality rate at BRI kept increasing and was double the rate at
    other centres
    Years BCI Others

    1984-89 32.2% 21.2%


    1989-90 37.5% 18.8%

    In the year 1991-95 the Bristol had over 30-35% excess deaths than
    others
    ➢ CEO John Roylance dismissed Dr. Bolsin’s complaints
    ➢ A series of six expose articles criticizing pediatric care published in
    Private Eye
    Problems at BRI
    ● The split-site and split-service issues
    ● Only two pediatric surgeons - one was unapproachable and
    the other was insecure to perform up to par
    ● Lacked a strong leadership and had lost trust of public
    leading to emotional contagion
    ● Repeated complaints and negative publicity
    ● The “muddling-through” mindset
    ● Behavioural commitment about lack of performance and
    higher mortality rate.
    ● Equity Theory and Organizational justice
    Personalities
    Dr. John Roylance Dr. James Wisheart Dr. Janardan Dhasmana

    CEO Paediatric Surgeon Paediatric Surgeon

    ● Transactional ● Autocratic ● Self Critical and insecure


    Leadership ● Counterproductive ● Lack of Self-
    (Laissez-faire) work behaviour Determination
    ● Lack of path-goal ● Position power ● Less engagement with
    theory behaviour exploitation surgical team
    ● Not a visionary ● Not an authentic leader
    Recommendation

    Variable Pay Program Feedback Relational Job Employee


    Design Involvement and
    Pay should depend on Feedback regarding Participation
    individual and effectiveness of Employees should Use input of
    organization performance should see the positive employees to
    performance be given difference they increase employee
    make commitment
    Recommendation

    Goal Setting Theory Mentoring


    Work Satisfaction

    Specific and difficult goals Senior employees should


    Support, security and with feedback leads to support less experienced
    psychological safety will higher performance doctors
    encourage collective
    responsibility
    THANK YOU
    THANK YOU

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