Leadership Assignment Quality

Leadership Assignment Quality

Documentation is an important factor to consider for consistent and high-quality patient care in every hospital. However, in the majority of healthcare organizations, documentation has become a big challenge. When it is properly developed and monitored in hospital, patients are more likely to be properly diagnosed and treated, which ensures that the goals of primary and compulsory medical care are guaranteed. Proper documentation is crucial, because it allows healthcare professionals to make diagnosis faster. Moreover, it is used for objective monitoring of disease progress and allows taking the appropriate measures, when needed (Williams, 2015). Our department lacks proper and legal documentation, which may lead to a number of medical errors. The purpose of this project is to come up with changes that can be implemented to provide adequate hospital documentation, hence contributing to proper and high-quality patient care.

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Most of the hospitals depend on electronic documentation, while others still rely on manual-based method. All these approaches are crucial, because they help in the organization of thoughts, identifying problems, and communication to other healthcare professionals. Finally, they are used for research and formulation of recommendation to improve the delivery of healthcare services. There are various gaps and documentation mistakes in a hospital. The errors may be witnessed in different ways. First, they may consist of failure to record patient drug information, to include nursing actions and medication, or to report reaction to a particular drug. Moreover, healthcare professionals are may write illegible records. All these mistakes in documentation process can alter the completion of duties in the medical profession (Williams, 2015). A practical and efficient documentation process should have such qualities as accessibility, accuracy, auditable, clarity and legibility. In other word, entries in each and, every document should be accurate, provide useful and truthful information, dated, stamped and use of standardized terminologies.

Change Theory Model

Various theories can be used to rectify the defective documentation process. Organizational and institutional change is not tragic, but its constituent culture will ensure that the institutions navigate and also enhance development. The theories of change are operational at all levels of the organization. Change within a particular department is personal, hence there is a need to involve all the stakeholders in the transformation process (March et al., 2000).  All the concerns raised by certain individuals should be addressed to avoid resistance in the implementation process. In addition, it is beneficial to have the required management skills during this stage. These skills include assessment of the project so that one can be in a position to predict the outcome.

Various theoretical steps can be utilized when implementing models of institutional change. Primary, it is important to identify the current situation in hospital. For our department, the current position is lack in proper documentation of medical records, and thus changes are much needed. The change process has three levels, which include the current, transition, and the desired state (March et al., 2000). The intended, or desired state, suggests having a reliable, efficient, and dependable documentation process within the unit. Lack of suitable documentation process has resulted in increasing patient demand and inefficient healthcare delivery process. The need for implementation of the change process can be explained by suffering from patients, wastage of time, and increased mortality rates within the facility. Such problems are the key for strong desire to implement the suggested changes for the improvement in organization functioning.

After defining the current state, the intended outcomes should be identified. It involves putting down achievable objectives after the change process, for example, coming up with performance targets or merits. The success of this stage solely depends on the initial definition of the institution needs for change. Additionally, it involves coming up with the departmental or the organization goals, decide, where the gaps exist, and finding their cause (Williams, 2015). The major goal in our case is to ensure proper legal documentation, which will safeguard lives and reduce time wastage in medical facilities. For example, disorganized documentation may be as a result of employee morale or even inadequate human resource. Management can come with ways of improving confidence or adding more workers to the facility. Performance gaps can be seen in failure of healthcare professions to record drugs given to the patient.

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An Approach in Communication Plan

The next step is informing all employees within the organization about the change plan. People have negative attitudes toward change, and thus, managers of change should present the need for this process persuasively and convincingly. The applied method seriously affects, whether the employees and medical practitioners will accept the idea, or not. The best way to manage this issue is to develop convincing argument in favor of the need to have improved documentation. For instance, proper documentation can help to reduce time wastage, lower the suffering of the patient, and minimize service costs. When explaining the performance gaps, change managers should even go an extra mile to tell some of the negative consequences of failure to implement the suggested changes (Williams, 2015). In this way, healthcare professionals can estimate the seriousness of the idea.

The fourth stage is planning for change, which involves coming up with new processes, putting up job descriptions, and predicting performance expectations. For the achievement of positive results, a number of management rules must be followed. The team must gain a consensus on goals and expectations within the organization. Moreover, they must develop a reliable plan for the implementation of the program. The resources that are needed in implementation process must be provided in time and have a realistic schedule (Williams, 2015).  The resources in our case may include computers to store documents, increasing the number of staff, or even purchasing files to save documents. The team ought to communicate the implementation process to other stakeholders.

After planning the next stage is application of change. To ensure that the process is properly performed, change managers should encourage suggestions from all stakeholders within the hospital. The significant change efforts include defining the tasks to be done, generating a system of management, which is capable of accomplishing the tasks, coming up with basic communication strategies, and monitoring resources availability. During the implementation phase, management should define goals, methods for their realization, and responsible persons. It should be mentioned that changes are usually followed by tensions and fear (March,et al., 2000). From the onset of change process, good leaders should put in place the communication strategies, especially to spread information to junior employees within the hospital.

The next step is evaluation of compliance, which measures the efficiency of implementation in achieving the suggested objectives. The monitoring process will guarantee proper utilization of resources, performance of duties, and evaluate the compliance level. When making changes, the governmental medical and professional policies should be taken itno account. A professionally document should be characterized by various qualities, including the age of the patient, patient social evaluation, person to be contacted, if there are an emergency.

The last part of the change process is to receive feedback from the system, that aims at providing information on the result of the change plan. The plan is essential, because it will help to identify, whether proper documentation process is a success or a failure. The feedback plan will determine, whether the objectives were realized and suggest the alternative strategy in case of failure. In addiiton, it will identify the responsible persons, who will continuously monitor the execution of the plan to point out errors and mistakes in the implementation process.

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Management Functions Utilized

For this model to be successful, there is a need to have teamwork and consultations at various levels of management. The model calls for a more democratic leadership, that will consult the employees in the decision-making process. The administration must also fulfill the functions, such as providing resources, hiring and motivating workers for the achievement of the set objectives. The proposed model has a number of advantages. When there is proper documentation, the cost of administration is reduced (Williams, 2015). Fewer employees will be needed, and most workers will concentrate on assisting patients at the individual level. The documentation will also reduce wastage of drugs and laboratory equipment. Meanwhile, patients will acquire affordable and efficient medical care, which will contribute to reduced risks for complications and mortality. The patients will be released on time, since healthcare professionals will make fewer mistakes under the presence of proper documentation, and make the treatment process more effective.

The following steps can be taken to solve the problem of documentation within a hospital. First, critical evaluation and treatment measures should always be documented. Staff should be educated about proper development of documentation scales and procedures. In addition, the medical team should come up with a new framework aiming at guiding and improving electronic health records. For instance, family members can be given a chance to access them. (Williams, 2015). Nursing treatment languages should be standardized, encouraging faster understanding of medical documents.

Services provided in a hospital must be made available on a 24-hour basis. They include nursing and physician resources, and drug availability. There is also the needed to come up with a disciplinary team that will make sure all the hospice services are provided with dignity and respect for human rights. If a patient is discharged or transferred from one facility to the next, the documentation must provide reasons for the transfer and failure of the previous unit to provide the required services.


Therefore, the process of implementation of change faces many challenges and barriers. Application of the described theoretical framework is very important, since it eliminates some possible problems and address the others. Most importantly, the change should not be measured by the achievement of objectives, but by the improvement in standards. Neither theory can guarantee changes, but with careful consideration, any can help to simplify this transition process. Change agents should know that implementation of changes, which are related to culture of an organization, can take time. Proper communication and consultation with majority of people and workers is likely to improve the chances for the acceptance and implementation of change by each individual. Communication becomes the motivation. Those employees, who were consulted at the initial stages, are more likely to participate in the implementation stage.

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