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      Patient SafetyRemove Patient Safety →

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      • September 2024
      • Case

      The Health Equity Accelerator at Boston Medical Center

      By: Susanna Gallani, Mary Witkowski and Katie Sonnefeldt
      This case describes how Boston Medical Center, a hospital and safety net organization, changed its strategic approach to health equity after realizing that previous efforts were not sufficient to address the health disparities among their patients. In 2021, the Health... View Details
      Keywords: Health Care and Treatment; Health Disorders; Innovation and Management; Innovation Leadership; Innovation Strategy; Adaptation; Business Strategy; Mission and Purpose; Decisions; Organizational Change and Adaptation; Organizational Structure; Diversity; Race; Ethnicity; Urban Scope; Local Range; Equality and Inequality; Health Industry; Boston
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      Gallani, Susanna, Mary Witkowski, and Katie Sonnefeldt. "The Health Equity Accelerator at Boston Medical Center." Harvard Business School Case 125-039, September 2024.
      • April 2024
      • Article

      Speaking up and Taking Action: Psychological Safety and Joint Problem-solving Orientation in Safety Improvement

      By: Hassina Bahadurzada, Michaela J. Kerrissey and Amy C. Edmondson
      Healthcare organizations face stubborn challenges in ensuring patient safety and mitigating clinician turnover. This paper aims to advance theory and research on patient safety by elucidating how the role of psychological safety in patient safety can be enhanced with... View Details
      Keywords: Healthcare Operations; Psychological Safety; Teams; Retention; Safety; Customer Satisfaction; Organizational Culture; Performance Evaluation; Health Industry
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      Bahadurzada, Hassina, Michaela J. Kerrissey, and Amy C. Edmondson. "Speaking up and Taking Action: Psychological Safety and Joint Problem-solving Orientation in Safety Improvement." Art. 812. Healthcare 12, no. 8 (April 2024).
      • 2023
      • Book

      Workplace Conditions

      By: Jill Maben, Jane Ball and Amy C. Edmondson
      This Element reviews the evidence for three workplace conditions that matter for improving quality and safety in healthcare: staffing; psychological safety, teamwork, and speaking up; and staff health and well-being at work. The authors propose that these are... View Details
      Keywords: Working Conditions; Outcome or Result; Safety; Well-being; Health Industry
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      Maben, Jill, Jane Ball, and Amy C. Edmondson. Workplace Conditions. Cambridge Elements, Improving Quality and Safety in Healthcare. Cambridge University Press, 2023.
      • July, 2022
      • Article

      Telehealth Visits After Shoulder Surgery: Higher Patient Satisfaction and Lower Costs

      By: Evan A. O'Donnell, Jillian E. Haberli, Andres Muniz Martinez, Daniel Yagoda, Robert S. Kaplan and Jon J.P. Warner
      Purpose and Methods: The study compared the cost of telemedicine visits with in-person clinic visits for routine follow-up after common shoulder surgeries. It also evaluated the safety and patient experience with telemedicine visits. Time-driven activity-based costing... View Details
      Keywords: Telehealth; Patient Satisfaction; Health Care and Treatment; Communication Technology; Health Industry
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      O'Donnell, Evan A., Jillian E. Haberli, Andres Muniz Martinez, Daniel Yagoda, Robert S. Kaplan, and Jon J.P. Warner. "Telehealth Visits After Shoulder Surgery: Higher Patient Satisfaction and Lower Costs." Journal of the American Academy of Orthopedic Surgeons Global Research and Reviews 6, no. 7 (July, 2022).
      • March 2021 (Revised January 2022)
      • Case

      Philips: Redefining Telehealth

      By: Regina E. Herzlinger, Alec Petersen, Natalie Kindred and Sara M. McKinley
      As one of the world’s largest healthcare companies, Philips sought to reach beyond the walls of the hospital and expand its hospital-to-home program to gain future competitive advantage through technology solutions combining predictive analytics with care delivery. By... View Details
      Keywords: Health Care; Philips; Visicu; Telemedicine; eICU; Accountable Care Organization; ACO; Bundled Payment; Hospital To Home; Patient Monitoring Devices; Home Health Care; Health Care and Treatment; Communication Technology; Quality; Safety; Performance Productivity; Performance Capacity; Performance Efficiency; Consumer Behavior; Emerging Markets; Health Industry; Telecommunications Industry; Netherlands
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      Herzlinger, Regina E., Alec Petersen, Natalie Kindred, and Sara M. McKinley. "Philips: Redefining Telehealth." Harvard Business School Case 321-135, March 2021. (Revised January 2022.) (As companion reading for this case, see: Regina E. Herzlinger and Charles Huang. "Note on Bundled Payment in Health Care," HBS Background Note 312-032.)
      • Article

      Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology

      By: Palak Kundu, Olivia Jung, Amy C. Edmondson, Nzhde Agazaryan, John Hegde, Michael Steinberg and Ann Raldow
      Background
      Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that... View Details
      Keywords: Psychological Safety; Near-miss Reporting; Health Care and Treatment; Safety
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      Kundu, Palak, Olivia Jung, Amy C. Edmondson, Nzhde Agazaryan, John Hegde, Michael Steinberg, and Ann Raldow. "Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology." Joint Commission Journal on Quality and Patient Safety 47, no. 1 (January 2021): 15–22.
      • Article

      The Inpatient Discharge Lounge as a Potential Mechanism to Mitigate Emergency Department Boarding and Crowding

      By: Brian Franklin, Sharif Vakili, Robert S. Huckman, Sarah Hosein, Nicholas Falk, Katherine Cheng, Maria Murray, Sheila Harris, Charles A. Morris and Eric Goralnick
      Delayed access to inpatient beds for admitted patients contributes significantly to emergency department (ED) boarding and crowding, which have been associated with deleterious patient safety effects. To expedite inpatient bed availability, some hospitals have... View Details
      Keywords: Health Care Delivery; Emergency Room; Operations Improvement; Operations Management; Health Care and Treatment; Service Delivery; Operations; Management; Performance Improvement; Service Operations
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      Franklin, Brian, Sharif Vakili, Robert S. Huckman, Sarah Hosein, Nicholas Falk, Katherine Cheng, Maria Murray, Sheila Harris, Charles A. Morris, and Eric Goralnick. "The Inpatient Discharge Lounge as a Potential Mechanism to Mitigate Emergency Department Boarding and Crowding." Annals of Emergency Medicine 75, no. 6 (June 2020): 704–714.
      • April 15, 2020
      • Other Article

      Designating Certain Post-Acute Care Facilities As COVID-19 Skilled Care Centers Can Increase Hospital Capacity And Keep Nursing Home Patients Safer

      By: Leemore S. Dafny and Steven S. Lee
      As the number of COVID-19 cases nationwide continues to grow, many hospitals will need to convert acute care beds into intensive care beds and discharge stable patients to post-acute care settings such as nursing homes. In addition, nursing homes unable to care for... View Details
      Keywords: COVID-19; Nursing Homes; Health Pandemics; Health Care and Treatment; Safety; Quality
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      Dafny, Leemore S., and Steven S. Lee. "Designating Certain Post-Acute Care Facilities As COVID-19 Skilled Care Centers Can Increase Hospital Capacity And Keep Nursing Home Patients Safer." Health Affairs Blog (April 15, 2020).
      • Article

      Psychological Safety and Near Miss Events in Radiation Oncology

      By: Palak Kundu, Olivia Jung, Kathy Rose, Chonlawan Khaothiemsang, Nzhde Agazaryan, Amy C. Edmondson, Michael L. Steinberg and Ann C. Raldow
      Background: Near miss events, defined as harm averted due to chance, are learning opportunities in radiation oncology. Psychological safety is a feature of a learning environment characterized by interpersonal risk taking. We examine the effects of near miss type and... View Details
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      Kundu, Palak, Olivia Jung, Kathy Rose, Chonlawan Khaothiemsang, Nzhde Agazaryan, Amy C. Edmondson, Michael L. Steinberg, and Ann C. Raldow. "Psychological Safety and Near Miss Events in Radiation Oncology." Journal of Clinical Oncology 37, no. 27 suppl. (September 20, 2019): 231.
      • November 2017
      • Case

      The 'Wonder Drug' That Killed Babies

      By: Joshua Lev Krieger, Tom Nicholas and Matthew Preble
      In the early 1960s, a popular drug taken by patients worldwide for a range of maladies was found to cause severe birth defects and other health problems in babies born to mothers who had taken it during a certain stage of fetal development. As many as 10,000 children... View Details
      Keywords: Regulation; Business and Government Relations; Business and Community Relations; Business and Stakeholder Relations; Product Marketing; Corporate Social Responsibility and Impact; Business History; Health; Government Legislation; Corporate Accountability; Ethics; Governing Rules, Regulations, and Reforms; Pharmaceutical Industry; Public Administration Industry; United States; United Kingdom; Australia; Germany; Europe
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      Krieger, Joshua Lev, Tom Nicholas, and Matthew Preble. "The 'Wonder Drug' That Killed Babies." Harvard Business School Case 818-044, November 2017.
      • August 2017
      • Case

      Infection Control at Massachusetts General Hospital (Abridged)

      By: Robert S. Huckman and Nikolaos Trichakis
      The case explores the challenges facing Massachusetts General Hospital concerning the adoption of a new infection control policy, which promises to improve operational performance, patient safety, and profitability. The new policy requires coordination between... View Details
      Keywords: Safety; Organizational Change and Adaptation; Integration; Health Care and Treatment; Policy; Health Industry; Boston
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      Huckman, Robert S., and Nikolaos Trichakis. "Infection Control at Massachusetts General Hospital (Abridged)." Harvard Business School Case 618-018, August 2017.
      • September 2015
      • Article

      Design and Implementation of a Privacy Preserving Electronic Health Record Linkage Tool in Chicago

      By: Abel Kho, John Cashy, Kathryn Jackson, Adam Pah, Satyender Goel, Jorn Boehnke, John Eric Humphries, Scott Duke Kominers and et al.
      Objective
      To design and implement a tool that creates a secure, privacy preserving linkage of electronic health record (EHR) data across multiple sites in a large metropolitan area in the United States (Chicago, IL), for use in clinical... View Details
      Keywords: Information; Customers; Safety; Rights; Ethics; Entrepreneurship; Health Care and Treatment; Health Industry; Chicago
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      Kho, Abel, John Cashy, Kathryn Jackson, Adam Pah, Satyender Goel, Jorn Boehnke, John Eric Humphries, Scott Duke Kominers, and et al. "Design and Implementation of a Privacy Preserving Electronic Health Record Linkage Tool in Chicago." Journal of the American Medical Informatics Association 22, no. 5 (September 2015): 1072–1080.
      • Article

      Time-Driven Activity-Based Costing: A Driver for Provider Engagement in Costing Activities and Redesign Initiatives

      By: Robert S. Kaplan, Nancy McLaughlin, Michael A. Burke, Nisheeta P. Setlur, Douglas R. Niedzwiecki, Alan L. Kaplan, Christopher Saigal, Aman Mahajan and Neil A. Martin
      Object. To date, health care providers have devoted significant efforts to improve performance regarding patient safety and quality of care. To address the lagging involvement of health care providers in the cost component of the value equation, UCLA Health... View Details
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      Kaplan, Robert S., Nancy McLaughlin, Michael A. Burke, Nisheeta P. Setlur, Douglas R. Niedzwiecki, Alan L. Kaplan, Christopher Saigal, Aman Mahajan, and Neil A. Martin. "Time-Driven Activity-Based Costing: A Driver for Provider Engagement in Costing Activities and Redesign Initiatives." Neurosurgical Focus 37, no. 5 (November 2014).
      • November 2013 (Revised November 2014)
      • Case

      Infection Control at Massachusetts General Hospital

      By: Robert S. Huckman and Nikolaos Trichakis

      The case explores the challenges facing Massachusetts General Hospital concerning the adoption of a new infection control policy, which promises to improve operational performance, patient safety, and profitability. The new policy requires coordination between... View Details

      Keywords: Safety; Organizational Change and Adaptation; Integration; Health Care and Treatment; Policy; Health Industry; Boston
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      Huckman, Robert S., and Nikolaos Trichakis. "Infection Control at Massachusetts General Hospital." Harvard Business School Case 614-044, November 2013. (Revised November 2014.)
      • September 2012 (Revised May 2015)
      • Case

      Philips-Visicu

      By: Regina E. Herzlinger, Natalie Kindred and Sara M. McKinley
      Would the advent of global payment models and ACOs create sufficient demand for a telemedicine offering covering the care continuum, from hospitals to the home? This was the decision facing Royal Philips Electronics (Philips), the Netherlands-based producer of... View Details
      Keywords: Health Care; Philips; Visicu; Telemedicine; eICU; Accountable Care Organization; ACO; Bundled Payment; Hospital To Home; Patient Monitoring Devices; Home Health Care; Health Care and Treatment; Communication Technology; Quality; Safety; Performance Productivity; Performance Capacity; Performance Efficiency; Consumer Behavior; Emerging Markets; Health Industry; Telecommunications Industry; Netherlands
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      Herzlinger, Regina E., Natalie Kindred, and Sara M. McKinley. "Philips-Visicu." Harvard Business School Case 313-015, September 2012. (Revised May 2015.) (As companion reading for this case, see Regina E. Herzlinger and Charles Huang, "Note on Bundled Payment in Health Care," HBS No. 312-032 (Boston: Harvard Business Publishing, 2012).)
      • October 2010
      • Case

      The Cleveland Clinic: Improving the Patient Experience (Abridged)

      By: Ananth Raman, Anita L. Tucker and Rachel Gordon
      Healthcare has traditionally focused on medical outcomes and financial performance. The big question is always, "How much is it going to cost?" What would happen though if healthcare also considered question of "How does the patient feel?" This case looks at the... View Details
      Keywords: Customer Satisfaction; Ethics; Health Care and Treatment; Six Sigma; Performance Improvement; Safety; Value Creation
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      Raman, Ananth, Anita L. Tucker, and Rachel Gordon. "The Cleveland Clinic: Improving the Patient Experience (Abridged)." Harvard Business School Case 611-015, October 2010.
      • September 2007 (Revised October 2007)
      • Supplement

      Children's Hospital and Clinics (B)

      By: Amy C. Edmondson, Ingrid M. Nembhard and Kate Roloff
      Explores the numerous initiatives Children's Hospital and Clinics has undertaken to improve patient safety since the late 1990s--from the perspective of 2007. The case thus updates the A case by revisiting the hospital to find out what happened as a result of the... View Details
      Keywords: Safety; Change Management; Organizational Culture; Organizational Structure; Legal Liability; Leadership; Management Teams; Health Industry
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      Edmondson, Amy C., Ingrid M. Nembhard, and Kate Roloff. "Children's Hospital and Clinics (B)." Harvard Business School Supplement 608-073, September 2007. (Revised October 2007.)
      • November 2001 (Revised September 2007)
      • Case

      Children's Hospital and Clinics (A)

      By: Amy C. Edmondson, Michael Roberto and Anita L. Tucker
      Describes the major phases of an initiative designed to transform the organization and enhance patient safety. Raises interesting questions about how to encourage candid discussion about failures while continuing to hold people accountable for their performance. View Details
      Keywords: Health Care and Treatment; Leading Change; Business Processes; Organizational Change and Adaptation; Organizational Culture; Performance Improvement; Safety; Health Industry
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      Edmondson, Amy C., Michael Roberto, and Anita L. Tucker. "Children's Hospital and Clinics (A)." Harvard Business School Case 302-050, November 2001. (Revised September 2007.)
      • November 2001 (Revised March 2002)
      • Case

      Digital Angel

      By: Youngme E. Moon and Kerry Herman
      Digital Angel is considering the appropriate marketing plan for the launch of its new locator device. The device, a watch and pager worn in combination, provides GPS location information and monitors heart rate and body temperature via body sensors. Parents of young... View Details
      Keywords: Information; Safety; Rights; Market Entry and Exit; Ethics; Product Launch; Brands and Branding; Product Development
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      Moon, Youngme E., and Kerry Herman. "Digital Angel." Harvard Business School Case 502-021, November 2001. (Revised March 2002.)
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