Category | Subcategories | Clinical example | Ethics example |
Management | (1) Maintenance of organisational resources(2) Budgets(3) Design/construction | Organisation’s handling of human resources (eg, staff selection, orientation, staffing) is inadequate to meet patient care needs. | The palliative care team of four consultants is only able to spend 30 minutes on average with each family due to their workload. |
(4) Availability | |||
Organisational culture | (5) Chain of command(6) Communication(7) Accountability(8) Informal culture | An appropriate decision-maker was not accessible or hierarchies of responsibility and authority to address differences of opinion or important concerns about patient care did not work (eg, the float respiratory therapist sought help from her respiratory therapist supervisor, who said she would be come help but never showed). | A nurse feels there is an ethical dilemma in need of addressing on her patient, but the attending physician ignores her concern. |
Transfer of knowledge | (9) Supervision(10) Training(11) Education | Supervision is not being provided to staff not yet functioning independently (eg, a resident physician ordered sedation on a patient despite the attending physician lacking sedation privileges). | Intern physicians on their first day in the neonatal ICU are instructed to counsel mothers in premature labour about the postnatal complications of a 24-week gestational age infant. |
Protocols and Processes | (12) Incentive systems(13) Time(14) Schedules(15) Documentation(16) Policies and procedures | Provider decisions are influenced by incentives, financial and otherwise (eg, a surgeon schedules more X procedures for which he receives a bonus payment). | Emergency physicians prioritise the patients they are most likely to discharge quickly first (not based on acuity) in order to improve their length-of-stay pay-for-performance metrics. |
(16) Policies and procedures | |||
(17) Discordance between goals/objectives and actions/decisions among staff; lack of agreement on goals of care among staff | |||
(18) Knowledge of organisational standard for performance |
ICU, intensive care unit.