{"id":{"repo_id":"uwo","oai_identifier":"oai:uwo.scholaris.ca:20.500.14721/26508"},"canonical_url":"https://search.dev.ndltd.org/etd/uwo/oai:uwo.scholaris.ca:20.500.14721/26508","repository":{"repo_id":"uwo","name":"Western University","base_url":"https://uwo.scholaris.ca/server/oai/request"},"display":{"title":"How to enhance communication among healthcare providers and improve patient safety","abstract":"In 2010, the Provincial Health Funder (PHF) mandated the reporting of unintentional adverse events that occur in the process of healthcare delivery, which result in disability, death, or prolong treatments. The results of reporting are available to the public on the Health Quality website, providing transparency for the public and accountability for Advanced Healthcare System (AHS)[1], which has made patient safety its organizational strategic priority (AHS, 2018). This Organizational Improvement Plan (OIP) seeks to improve communication and positive change among healthcare providers by maximizing the use of error prevention tools to improve patient safety. The principles of distributive and transformational leadership are applied to enhance collaboration, build capacity, empower people to speak up for safety, and enhance team decision making. The organizational plan aligns with my leadership philosophy to develop others, as well as abide by the Social Work regulatory body’s ethical standards, which guides my work as a change agent to support the best interest of others. Systems theory guides the plan and Bolman and Deal’s (2013) four frame conceptual framework is used to enhance the understanding of the existing state of the organization, which currently includes challenges in communication, a culture of “blame and shame”, insufficient use of error prevention tools, and patient harm. The Murray and Richardson (2002) framework is utilized to guide the OIP and identify ten “winning conditions” to address the problem from a holistic standpoint, while encompassing speed and momentum. Keywords: patient safety, error prevention tools, culture of blame and shame, capacity building, organization culture [1] Advanced Healthcare System (AHS) is a pseudonym to protect the identity of the facility.","abstract_html":"In 2010, the Provincial Health Funder (PHF) mandated the reporting of unintentional adverse events that occur in the process of healthcare delivery, which result in disability, death, or prolong treatments. The results of reporting are available to the public on the Health Quality website, providing transparency for the public and accountability for Advanced Healthcare System (AHS)[1], which has made patient safety its organizational strategic priority (AHS, 2018). This Organizational Improvement Plan (OIP) seeks to improve communication and positive change among healthcare providers by maximizing the use of error prevention tools to improve patient safety. The principles of distributive and transformational leadership are applied to enhance collaboration, build capacity, empower people to speak up for safety, and enhance team decision making. The organizational plan aligns with my leadership philosophy to develop others, as well as abide by the Social Work regulatory body’s ethical standards, which guides my work as a change agent to support the best interest of others. Systems theory guides the plan and Bolman and Deal’s (2013) four frame conceptual framework is used to enhance the understanding of the existing state of the organization, which currently includes challenges in communication, a culture of “blame and shame”, insufficient use of error prevention tools, and patient harm. The Murray and Richardson (2002) framework is utilized to guide the OIP and identify ten “winning conditions” to address the problem from a holistic standpoint, while encompassing speed and momentum. Keywords: patient safety, error prevention tools, culture of blame and shame, capacity building, organization culture [1] Advanced Healthcare System (AHS) is a pseudonym to protect the identity of the facility.","abstract_has_math":false,"creators":["Gordon, Heather"],"institution":null,"degree_name":"Doctor of Education","degree_level":null,"degree_discipline":"Education","degree_department":null,"school":null,"contributors":[],"advisors":["Brook, Paula","Bauman, Cheryl"],"committee_chairs":[],"committee_members":[],"year":2019,"date_issued":"2019-08-27","date_published":"2019-08-27","updated_at":"2026-07-27T21:56:20Z","subjects":["Patient safety","Error prevention tools","Culture of blame and shame","Capacity building","Organizational culture"],"languages":["en_ca"],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://hdl.handle.net/20.500.14721/26508","outbound_label":"Handle","outbound_source":"dc:identifier.uri"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor.advisor","label":"Advisor","values":["Brook, Paula","Bauman, Cheryl"]},{"key":"dc:creator","label":"Author","values":["Gordon, Heather"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.accessioned","label":"Dc Date Accessioned","values":["2025-06-30T18:47:10Z"]},{"key":"dc:date.available","label":"Dc Date Available","values":["2025-06-30T18:47:10Z"]},{"key":"dc:date.issued","label":"Date","values":["2019-08-27"]},{"key":"dc:type","label":"Dc Type","values":["thesis"]},{"key":"thesis:degree_discipline","label":"Discipline","values":["Education"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Doctor of Education"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Patient safety","Error prevention tools","Culture of blame and shame","Capacity building","Organizational culture"]}]},{"id":"language_rights","label":"Language and Rights","entries":[{"key":"dc:language.iso","label":"Language (ISO)","values":["en_ca"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier.uri","label":"Identifier URI","values":["https://hdl.handle.net/20.500.14721/26508"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description","label":"Description","values":["The thesis cover page in the PDF document includes references to Western University’s previous institutional repository platform, known as Scholarship@Western, and links to that platform (beginning with ir.lib.uwo.ca). In citing or referring to this thesis, use the DOI or handle from this page instead. Sample citation: Author name, \"Thesis title.\" (Year). Western University Open Repository. https://doi.org/10.71858/123456."]},{"key":"dc:description.abstract","label":"Abstract","values":["In 2010, the Provincial Health Funder (PHF) mandated the reporting of unintentional adverse events that occur in the process of healthcare delivery, which result in disability, death, or prolong treatments. The results of reporting are available to the public on the Health Quality website, providing transparency for the public and accountability for Advanced Healthcare System (AHS)[1], which has made patient safety its organizational strategic priority (AHS, 2018). This Organizational Improvement Plan (OIP) seeks to improve communication and positive change among healthcare providers by maximizing the use of error prevention tools to improve patient safety. The principles of distributive and transformational leadership are applied to enhance collaboration, build capacity, empower people to speak up for safety, and enhance team decision making. The organizational plan aligns with my leadership philosophy to develop others, as well as abide by the Social Work regulatory body’s ethical standards, which guides my work as a change agent to support the best interest of others. Systems theory guides the plan and Bolman and Deal’s (2013) four frame conceptual framework is used to enhance the understanding of the existing state of the organization, which currently includes challenges in communication, a culture of “blame and shame”, insufficient use of error prevention tools, and patient harm. The Murray and Richardson (2002) framework is utilized to guide the OIP and identify ten “winning conditions” to address the problem from a holistic standpoint, while encompassing speed and momentum. Keywords: patient safety, error prevention tools, culture of blame and shame, capacity building, organization culture [1] Advanced Healthcare System (AHS) is a pseudonym to protect the identity of the facility."]},{"key":"dc:title","label":"Title","values":["How to enhance communication among healthcare providers and improve patient safety"]}]}],"canonical_facts":{"dc:contributor.advisor":["Brook, Paula","Bauman, Cheryl"],"dc:creator":["Gordon, Heather"],"dc:date.accessioned":["2025-06-30T18:47:10Z"],"dc:date.available":["2025-06-30T18:47:10Z"],"dc:date.issued":["2019-08-27"],"dc:description":["The thesis cover page in the PDF document includes references to Western University’s previous institutional repository platform, known as Scholarship@Western, and links to that platform (beginning with ir.lib.uwo.ca). In citing or referring to this thesis, use the DOI or handle from this page instead. Sample citation: Author name, \"Thesis title.\" (Year). 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