Reference no: EM132970453

Case:

The Case of Jesica Santillan

It is extraordinarily difficult to manage communications in health care settings. Few cases offer a better illustration of that difficulty than Jesica Santillan's. She was a 17-year-old girl who died in 2003 after undergoing a heart and lung transplant at one of the nation's top medical centers in which she received organs with the wrong blood type.

Her tragic story shows how social, technical, and organizational complexities combine to create daunting communication barriers for health providers and administrators. Consider the complicating factors in this situation and the related leadership questions they raise:

• The Family. Jesica's parents smuggled her into the country from Mexico, hoping to find a cure for a heart and lung disorder that doctors in her home country could not treat. The family settled in North Carolina, settling down in a trailer. They soon came to the attention of a local builder, who started a charity that eventually raised enough money for her to receive a transplant at Duke Medical Center. The procedure went terribly wrong, leading to severe and irreversible brain damage. When the doctors informed Jesica's mother that they planned to stop treatment, she announced at a press conference, through a translator, "They are taking her off of the medicine little by little in order to kill her. They want to rid themselves of this problem."

Questions:

1. Leadership question: What social and cultural barriers may have made it difficult for the doctors to communicate with Jesica's family? What might have the doctors done to increase the chances that Jesica's family understood the true nature of the problems in this terrible circumstance?

• The Procedure. A heart and lung transplant is obviously a challenging procedure. Though Dr. James Jaggers, the chief of pediatric surgery at Duke University, was a highly skilled and well-regarded physician, he was just one among many professionals involved in a multistep process that began with the location of suitable organs somewhere in North America and continued through transferring the patient to the intensive care unit (ICU). The many handoffs required in this process meant there was a risk of important information being lost or garbled at key transition points, as in the "whisper down the lane" game. This is in fact what happened. Jesica Santillan's blood type was O, while the organs' was A. Carolina Donor Services located the organs and, they claimed, informed Dr. Jaggers of the organs' blood type. Dr. Jaggers does not remember the conversation about it. Another physician was sent to pick up the organs in Boston. He was informed three times of the blood type, but since he did not know Jesica's blood type, he was not aware there was a mismatch.

Question 2

Leadership question: How would you organize the complex set of steps required in this transplant process to ensure that misunderstandings do not occur in handoffs between professionals?

• The Stakeholders. Following the string of errors leading to the mistaken transplant, the Duke Medical Center had to manage a whole set of stakeholders: the Santillan family, the family's lawyers, the community, the press, and the health provider community. Each stakeholder group had its own interests, influenced by its cultural, social, and professional backgrounds.

Question 3

1. Leadership question: If you were the Duke Medical Center CEO, what general communication strategy would you put in place to manage the stakeholders in this case? In particular, how would your messages to each group differ from the others?

Book referances: Burns,l.,Bradley,E.,Weiner,B. (2012). Shortell and Kaluzny's Healthcare Management: Organization Design and Behaviour (7th ed.).