DRAFT: This module has unpublished changes.

Reflection On Organizational Change Effort

 

Hannah Hohendorf

 

Assignment Date: May 13, 2016

 

The first big project that I was made a part of at St. Joseph Hospital was working on improving the transfusion reaction monitoring program. The group that spearheaded the effort was the transfusion safety committee, of which I am a part as the acting transfusion safety officer (TSO). To begin, a literature review was done to make sure that all changes made were evidence-based. Then, members of the committee discussed the literature and, after reviewing vital sign timing, vitals taken, and transfusion reaction symptoms, the committee voted to approve the changes and proceed to implementation.

 

As the TSO, I was in charge of implementing the changes, so I entered a change request to update the electronic transfusion vital monitoring program to include the changes that had been approved. There were three requests entered and two were rejected. The third still has a decision pending. Currently the project is stalled as we wait for a decision on the last request.

 

This project could have been executed with more skill. The biggest problem that I encountered was miscommunication. If I was able to do it again, I would first become acquainted with the entire transfusion administration process from start to finish by watching transfusions as they were occurring. This would have allowed me to get a better picture of what nurses do during each phase of the transfusion and the current guidelines would have had better context during the literature review. Also, I would not have had a filtered view of what was happening by asking nursing leaders.

 

Performing the literature review itself went well and was well received by the committee. Also, the changes to the vitals and symptoms were well-documented for reference during implementation.

 

The next part that I would change would be contacting more information technology (IT) staff to discuss the changes we wanted to make and how they would affect the current information system settings. The two rejected change requests were rejected because the current system was already set up to do what we had asked. This showed how little I knew about the system and my skewed view of its functionality. If we had been in regular communication with the people behind the electronic record system, we would have known where we needed to make changes.

 

This project was started in December of 2015 and is still pending resolution. I have entered change requests that were a waste of time for the committees in charge of reviewing them and we have not made significant progress toward updating our processes. As my first project as TSO, the first phase was a complete failure. However, I am determined to learn from these mistakes and to do it right moving forward.

 

On this second work-through, I will receive training in transfusion administration from the clinical education team so that I will know what to expect on the floor. Next, I will be observing blood transfusions, for a week, as they occur so that the entire process is clarified through experience. Then, I will take my new experiences and apply what I have learned to the problems in transfusion reaction monitoring. Throughout all of these steps I will work on building communication with the necessary stakeholders (IT, nurses, other TSOs) so that the mistakes of the first phase are not repeated. All of this will be done over the next month so that this project may be brought back on track.

 

Unit5IndivAssignment.pdf

DRAFT: This module has unpublished changes.