Public inquiry into a health system failure

Both nationally and internationally, there have been public inquiries into the failure of health systems to deliver safe and evidence based care. The recent investigation into the series of clinical incidents and clinical governance issues concerning the provision of maternity services at Djerriwarrh Health Services, Bacchus Marsh, Victoria, Australia is a high profile example. This assessment requires you to explore this prominent inquiry and to answer the question/s posed in two only of the four modules below;  Clinical Governance  Safety and Quality  Leadership and Management  Organisational Culture A brief introductory paragraph is required to identify which two modules you will address in your response (this paragraph is not included in the work limit). As a scholarly piece, please use a third person writing style. Your response for each module will be 500 words (1000 words in total). A brief list of resources has been provided in the assessment section of the LMS to assist you in beginning to explore the context of this health service inquiry. You must support your assertions with evidence from additional sources of contemporary literature. 1. Clinical Governance Clinical governance is defined in the Victorian Clinical Governance framework (2017) as: “..the integrated systems, processes, leadership and culture that are at the core of providing safe, effective, accountable and person-centered healthcare underpinned by continuous improvement. There are five domains in this refreshed clinical governance framework. Within the five domains, key systems and practices are required to support safe, effective, person-centred care for every consumer, every time. From the model above, identify two domains. Describe how these two domains may have influenced the system failure in the Bacchus Marsh healthcare service public inquiry. Use the literature to support your assertions. 2. Quality and Safety Identify and describe a risk management strategy that the Bacchus Marsh healthcare service could have undertaken to prevent the health system failure. Such strategies may include:  Credentialing  Reporting and acting upon near misses and incidents  Accreditation and benchmarking  Auditing  Monitoring and responding to complaints. How might the implementation of this risk management strategy have changed the outcome in your chosen inquiry? 3. Leadership and management Identify and describe two traits/characteristics of an open and transparent leader. Were the characteristics evident in the key figures in the Bacchus Marsh inquiry? Use the evidence from the inquiry to support this assertion. Briefly examine how these characteristics influence the delivery of safe patient care. Use evidence from contemporary literature to support your assertions. 4. Organisational culture Define the term Whistle-blower. Describe what influence the organisational culture have on the quality of care in your chosen inquiry? Did the culture of the Bacchus Marsh healthcare service help to hide or disclose the failure? Justify your response with evidence from the literature.

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