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Improving the Quality of Healthcare in Hong Kong


Choosing ONE of the provided scenarios, analyse the identified health care problem. Apply Ishikawa’s FishBone Analysis, Lewin’s Force Field Analysis and Clinical Governance Strategies within your analysis, in order to improve practice in the given health care area


Scenario 1

Retained instruments or other material following surgery. Retained Guidewire

A patient with a cervical cord transverse myelitis was prescribed plasmapheresis as her disease did not respond to pulse steroid therapy. Double lumen catheter insertion was required for plasmapheresis. During catheter insertion, pre procedural checking and TIME OUT were performed. During post procedural checking, the guidewire was not found. However, the box for ‘Guidewire Removed’ was ticked in the post procedural checklist. On the next day, a retained guidewire was noted on the chest x ray. The retained guidewire was removed intact under image guidance 12

The three scenarios used for the assignment question, are based on reports and plans related to health care within Hong Kong.


Scenario 2

Death of an inpatient from suicide (including home leave)

A patient with a history of paranoid schizophrenia and multiple hospital admissions was admitted for psychosis. After symptoms improved, rehabilitation and occupational therapy training were arranged for him. At a multidisciplinary recovery meeting two months prior to the incident, he was granted as- needed day leave with staff for rehabilitation activities.

On the day of the event, the patient went on day leave with a family member after an assessment had been completed. Two hours later, the family member informed the ward staff that the patient had jumped from a height at home.


Scenario 3

Patient -Food Services. Hygiene and safety

Following an outbreak of salmonella poisoning in a hospital in Hong Kong – three elderly patients died. Following a review, improvements were considered to be needed in the storage and staff handling of patient food.


Reports Include –

‘The Annual Report on ‘Sentinel and Serious Untoward Events’ published by the Hong Kong Hospital Authority (Jan 2019) (accessed 24.09.2019)

‘The Hospital Authority Annual plan’ (2019-2020) (accessed 24.09.2019)

  1. ‘The Annual Report on Sentinel and Serious Untoward Events 2017- 2018 published by the Hong Kong Hospital Authority (Jan 2019), identified 22 Sentinel Events and 83 Serious Untoward Events.

Within the ‘Sentinel Events’ there were ten cases of retained instruments or other materials after surgery or interventional procedures, (p46). There were seven cases of inpatient suicide (including home leave), (p52)

  1. Within ‘The Hospital Authority Annual Plan’ 2018-2019, Patient Food Services, specifically hygiene and safety standards were considered to need enhanced surveillance, (p45)


The essay should be richly referenced. It is important to read widely, critically appraise the literature and apply to your discussion.

Please DO NOT copy content from the LSM because this does not demonstrate learning and therefore will not gain good marks and might be considered plagiarism 


Guidelines for the Essay


1. Introduction (300 words)

Signpost the reader by identifying the structure of your essay i.e. explain what you are going to write about. Identify your chosen scenario.


2. Main Body (2,500 words)

Select one of the scenarios, address ALL A – E below


A. Discuss the meaning and importance of clinical governance and link this discussion to Total Quality Management (TQM) and the 2019 – 2020 HA Annual Plan / Report and Sentinel Events (2019).


B. Ishikawa’s FishBone Analysis

Use the ‘Ishikawa’s Fishbone’ diagram to analyse the cause of your chosen scenario.

Then, summarise and critically discuss the key identified causes for the problem and the areas of practice that need to be changed

Discuss the strengths and weaknesses of the tool

(The fishbone diagram must be included. If you cannot draw the fishbone on the computer then draw it by hand and scan the figure into your assignment. Please ensure that work is legible. You can download a ‘fish’ from Google)


C. Lewin’s Force Field Analysis.

After identifying areas for change –

Discuss how Lewin’s force field analysis can help staff to change practice.

In relation to your chosen scenario and issues identified in your Fish Bone diagram, critically discuss how Lewin’s Force Field Analysis can help staff to identify the resisters against and forces for, identified changes needed in practice.

Include the diagram to identify the resistors and drivers that will enable change.

(If you cannot draw the Force Field diagram on the computer then draw it by hand and scan the figure into your assignment. You could download a force field analysis diagram from google)


D. Clinical Governance strategies.

Select two clinical governance strategies and critically apply to your chosen scenario in order to suggest how the incidence of the problem could be reduced.

Ensure that you apply your chosen Clinical Governance Strategies to the key causes identified in the Fish Bone Analysis and resistors against and forces for change identified in Lewin. Make specific suggestions as to how you may do this.

e.g. More education needed for staff in relation to understanding policy, the use of risk analysis or quality circles in identifying potential problems etc.


E. Audit and SMART Standards.

With reference to your chosen Clinical Governance Strategies, discuss AUDIT as a third Strategy. What is the aim of carrying out audit and which method(s) of audit could you use to monitor any affected change.

Discuss the importance of SMART standards and identify one standard for each of the 2 Clinical Governance strategies that you have discussed. (Do not set a standard for Audit)


3. Conclusions (200 words)

Summaries the key points discussed in your essay, do not describe the structure.

It is important not to bring any new ideas or literature into the conclusion



Guidelines for the Essay


  1. Discuss the meaning and importance of clinical governance and link this discussion to Total Quality Management and the HA 2019-20 Annual Plan
  2. Select one of the scenarios below (taken from Health Authority annual plan / Sentinel Events Reports)
  3. Use Ishikawa’s fishbone to analyse the causes of the problem in your chosen scenario.
  4. Discuss Lewin’s Force Field Analysis to assist in changing practice
  5. Select and discuss two clinical governance strategies and critically apply to your chosen scenario in order to suggest how the incidence of the problem could be reduced.
  6. Discuss the importance of audit as third strategy to monitor any effected change
  7. With reference to you Clinical Governance Strategies, discuss the importance of SMART standards and identify one standard for each strategy
  8. Conclusion

There are many literatures that define the meaning of clinical governance such
as Som (2004), Swage (2004) and Sale (2005). Som (Som, 2004, p.89) emphasized
an integrated approach of inputs, structure, processes and outcomes quality
improvement, with considering staff accountability and environmental culture. Clinical
governance is important as it is an integrated structure that enable an organisation to
improve the quality through Total Quality Management. All aspects of quality are
included so that they can be continuously monitored. Staff are accountable and
customers are engaged (Gottwald and Lansdown, 2014). Sale (2005) suggests
clinical governance is a framework which can be represented as 7 aspects. They
are: quality circles, evidenced based practice, risk management, education and
training, complaints management, integrated care pathways, and audit. Moullin
(Moullin, 2002, p.38) state total quality management is ‘An ongoing process,
requiring commitment from top management and involving everyone in the
organisation, to meet the requirements of service users and other stakeholders while
keeping costs to a minimum’. The Hospital Authority Annual Plan 2018/19 (Hospital
Authority, 2018) emphasizes on planning and implementation to attain five clinical
governance strategic goals. Example highlights are: improve service quality (quality
circles), attract and retain staff (risk management), enhance staff training and
development (education and training). It also emphasizes on it is an ongoing
improvement process (total quality improvement) to meet public requirements with
optimal financial resources, which implies to ensure that quality health care is not
only delivered safely but continuously updated and improved. Besides, Hospital
Authority Annual Report on Sentinel Events is studied and linked to risk
management incorporated to other clinical governance aspect such as education
and training, quality circles and audits.
This essay will at first discusses the importance of Clinical Governance. Then it
will analyse the causes of medication error by using Ishikawa fishbone. How the
Lewin’s force field analysis can help to change will also be discussed. The clinical
governance strategies of Education and Training and Risk Management will be
discussed in relation to medication errors and finally Audit will be discussed and
SMART standards identified. Finally, the key points in this essay will be summarised
in the conclusion.
Main body
Administration of medication is one of the daily nursing practice. In fact,
medication errors are a common incidence among the clinical error reports in public
healthcare practice (Gottwald and Lansdown, 2014). In the period from October
2017 to September 2018, there were total 76 untoward medication errors, 7 due to
patient misidentification reported in public hospital in Hong Kong (Hong Kong
Hospital Authority, 2019). In this assignment medication error was chosen to analyse
the possible causes. In order to reduce medication error, this assignment is going to
looking for the causes of this quality problem by using Ishikawa’s fishbone (Ishikawa,
Ishikawa fishbone (Ishikawa, 1985) is used to analyse the causes of quality
issue. All the possible causes are listed systematically in a fish shape diagram the
cause-effect relationship are displayed graphically. This tool is commonly used in
root cause analysis as well as cause and effect analysis. In case of root cause
analysis, the cause of each fragment of the bone would be discussed in-depth and to
be identified separately (Gottwald and Lansdown, 2014). In order to be more simple
to begin with, the cause and effect analysis is used in this assignment. The diagram
illustrates the head is the problem and the bones are the causes. Besides this, the
strengths of this tool also includes being simple to use and clear presentation for
easy read and understand. In contrast, there some limitations that fishbone only
provides an easy approach to identify the key causes but there is no solution is
provided to solve the problem. Also, the fishbone does not prioritise the causes to
solve the problem (Gottwald and Lansdown, 2014).
The following fishbone diagram shows the possible causes of medication
error found in the chosen scenario situation. The fishbone is illustrated in 4Ps: Place,
Policy, People and Procedure. The key causes identified are highlighted in the
Busy ——————- Not follow the procedure —
Shortage of staff ——— Not using 3 checks 5 rights—
Distraction ———————-
Causes of medication by using Ishikawa’s fishbone (Ishikawa, 1985)
Causes of medication error by using Ishikawa’s fishbone (Ishikawa, 1985)
Poor perception in
Counter checking ————– Lack of continuous training —–
Lack of knowledge—- Lack of communication ————–
In the aspect of the Place. In Scenario 2 the hospital ward the environment
was busy. The busy environment might due to shortage of nursing staff. In recent
years, the problem of global shortage of nurses is becoming more severe that
affecting the quality of care (Chan et al, 2012). Among the public hospitals in Hong
Kong, Nurse-to-patient ratio may be 1 to 13 or even worse (Chan et al, 2012). Also,
any unexpected issues would distract nurse’s attention that making them difficult to
concentrate in checking and calculating drug dosage. The situation may be
deteriorated during visiting hours as the interruptions from patients and their relatives
would increase the workload of nurses.
Secondly, in the aspect of the People, nurses involved in this medication
error were working in a busy ward. The first nurse administered the medication alone
without counterchecking with another nurse against the prescription. Besides, she
just put the drug on bedside without asking the right patient to take the medication
instantly and did not witness the right patient taking the drug. The second nurse
wanted to finish the task of giving medications in hurry by just asking a patient
without checking patient’s identity. Also, it was observed that the second nurse did
not check the medications against prescription. It showed that both nurses had
inadequate basic concept on 3 checks 5 rights as safe administration of medication.
Therefore, one of the causes of this medication error was identified as they had
problem of lack of knowledge in both administration of oral medication as well as
medication safety.
The third aspect is to looking at the Procedure. Both nurses in the chosen
scenario were observed to seek for convenience and did not follow the 3 checks and
5 rights procedural rule. In case of high risk medication, they even did not obey the
guideline of high risk medication. Morphine was belonged to the category of
dangerous drug. In this incidence the two nurses had neglected the procedure rule
by not complying the counter-checking procedure against two qualified nurses.
Instead, the second nurse just asked a different patient if those were her drug
without checking patient’s identity against the prescription. Therefore, one of the
causes of this medication error was identified as they did not comply the 3 checks 5
rights procedure.
The fourth aspect would be the Policy. As mentioned, both nurses involved
in this medication error were observed to be lack of awareness or knowledge in the
policy of proper administration of oral medications as well as concept in medication
safety. It indicated that they did not meet the required knowledge standards to
ensure they were capable of delivering quality care. In consideration of cause and
effect relationship, insufficient training led to lack of knowledge to perform high
standard care, which causing poor quality of care issue such as medication error.
Learning implies someone to change in knowledge, skills, attitude as well as
behaviour (Gottwald and Lansdown, 2014). Besides, continuous education and
training could enhance communication to inform staff on any updated drug policies
as well as a warm reminder on medication safety.
After working the Ishikawa’s fishbone to the medication error in the chosen
scenario, it was identified that the main causes linked to the incidence were failure to
comply 3 checks and 5 rights rule, lack of training and busy-ness.