Task

This task requires you to provide safe patient care by applying clinical leadership skills, clinical governance processes and a change management model.

Review the patient incident in the coroner’s report below, then identify areas where leadership and governance failed. Identify relevant change opportunities related to the errors found in the report, and discuss potential challenges when implementing change in the clinical practice environment.

Coronial Naomi Williams an Aboriginal woman from Tumut

10.4.23

Amendment: Link to Gov site above has ‘dropped out’.

To access Coronial report follow the below link, ensure the date is entered as 2019 and enter Namoi’s name. This will open a new window with a download button visible.

https://www.coroners.nsw.gov.au/coronial-findings-search.html?searchtext=Naomi%20Williams&searchYear=2019

Assessment Criteria

You will be assessed on your ability to:

1. Refer to the EQuIP 6 Standards and Criteria to identify 3 criteria/standards that were not met and negatively impacted the care of Naomi Williams.
   2. Discuss the interrelationship between clinical leadership and clinical governance in ensuring safe, quality patient care in the case study; then using the Swiss Cheese Model of Accident Causation, identify the systems and processes that resulted in the errors that led to the death of Naomi Williams.
   3. Review the coroner’s recommendations and identify areas for change. Using Kotter’s 8-step change management model, justify how you would put the changes into practice.
   4. Write the essay in academic style and provide references using APA 7th edition.

Find the EQuIP6 Standard document  below:

Kotters 8 step change management

1. Create a sense of urgency
2. Build a guiding coalition
3. Develop a strategic vision & initiatives
4. Enlist a volunteer army
5. Enable action by removing obstacles
6. Generate short-term wins
7. Sustain acceleration
8. Institute change