Essay on Case Study

Submitted By juse-Xu
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Case study of fixing healthcare from the inside
Yidong Zhu
Statement of the problem
Many policy makers and management scholars believe that the problems with American health care are rooted in regulatory and market failures. They think the best treatment is strengthening market mechanisms. While, the author believes that market-based solutions will cause professionals and policy makers to ignore opportunities for improving health care’s quality, increasing its availability, and reducing its cost.
The problem happens in the industry which can be solved without market-based solutions is the ambiguity and the work-around culture. That makes trouble. In the ICU, professionals don’t know who should take charge of the patient which delays the cure. In the treatment, nurse uses the wrong medicine.

Analysis
Those situations happen many times in the industry. What is the root cause? What we can do?
Many reasons can lead to such mistakes. Ambiguities are everywhere. That’s the main reason lead to so many mistakes in healthcare delivery.
For Mrs. Grant story, medicine with the similar size and shape, with labels that were hard to read and they were located next to each other on the cart were the root cause. If nurses can work carefully maybe they could aware the mistake and correct it. And in most of time, they can figure it out and correct it immediately. However, the reality is, nurses work 12 hours a shift and they are tired with delivering care to 4 or 5 patients. That makes them easily ignore the difference between the similar vials. While, there are still opportunities there. We can make the vials in different size. If they are in the same size, we can put different label on it. In addition, we can put them on different location in the same cart, or put big label on the cart to remind nurses.
For the boy’s case, the involved professionals didn’t have the clear responsibility made the boy died. They should work as a team, they are not insulation. Everybody in the team should speak out their voice to provide contribution to the case. Not individual in the team take responsibility for the boy, the team should.

Recommendations
Learn from other industry and improve from small changes
TPS- Toyota production system.
There are three principles of TPS: All work shall be highly specified as to responsibility, content, sequence, timing and
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