James Reason's Swiss Cheese Theory – Health System Example

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"James Reason's Swiss Cheese Theory" is an exciting example of a paper on the health system.   Researcher James Reason proposed the model of “ Swiss cheese” . The Swiss cheese model is an accident causation model used in risk analysis as well as in risk management. The model explains the amount of system malfunction such as health-related mishaps. The model depicts that it has many layers of defense lie between the hazards and actual occurrences of accidents. However, there are holes or weaknesses in each layer. These are changeable that are holes open or close randomly-hence there is a similarity with the concept of Swiss cheese.

When these holes in each layer are aligned, then the hazards can harm the patient. Leadership is the most critical function in promoting safe health care in the hospital industry. In health care organizations, the managing body of senior managers, physicians, and clinical staff provide leadership. It has been seen that leadership made a major difference in the overall quality and safety of patient care. In this study, we will evaluate two specific leadership groups who are directly responsible for the patient care that is medical administrative leaders and the physician-clinical staff leaders.

The managing body of the organization controls the overall operation of the organization. These leaders strategically plan the organization’ s mission vision and goal. Provision of services, priorities for improvements, etc. strategic decisions are taken by these leaders. They are the people who are ultimately accountable for safety and quality issues. Physicians are licensed practitioners. They are the main leader of the medical staff. The physicians take all decisions about diagnosis or treatment. However, clinical staff supervised the care prescribed by the physicians (Fraczkiewicz-Wronka, Austen & Wronka, 2010).

The collaboration of medical staff helps the organization to achieve safe and quality patient care. The following strategies can be taken to improve leadership: There should be a shared goal, vision, and mission among the leaders. Clarity about the individual role. Effective communication with each other and understanding others' roles. Mutual trust. If the above strategies can be applied then the member would develop skills and attitudes, which are necessary for collective function. The workers of a hospital should work as a team for the purpose of safety and patient care. To increase collaboration among the leading groups it is necessary to eliminate the disagreement and conflict among them.

To address this problem following measures can be taken: Providing opportunities to share information in a way so that it will reduce the conflict and making proper decisions. Introducing a proper code of conduct to encourage civility and mutual trust. The leaders need to train with organizational culture to incorporate goals related to safety and quality of patient care. In the health care industry, the Swiss cheese model is widely accepted for patient safety purposes (Joint Commission, 2009).

Hospital administrators can involve in the following activities to improve the quality of the service and to mitigate the risk. Establishing specific quality-related goals to evaluate the organization’ s process and its outcomes. Promoting organization safety culture, which includes a code of conduct for the workers. Arranging regular seminars or other programs that focus on the safety issues related to patient care. Providing training and consultative services to individual departments. Identifying opportunities for the purpose of continuous improvement. Evaluating customer feedback and initiating improvement activities based on the findings. The primary responsibility of hospital staff is to provide safety-related to treatment and service.

To achieve the purpose alignment among the leading groups with respect to the organization’ s goals is necessary. It will also facilitate teamwork and reduce risk.


Fraczkiewicz-Wronka, A., Austen, A., & Wronka, M. (2010). An empirical research on the leadership and effectiveness in public healthcare organizations: Lesson from a transition economy. Journal Of US-China Public Administration, 7(2), 1--15.

Joint Commission,. (2009). Leadership committed to safety (1st ed.). Retrieved from http://www.jointcommission.org/assets/1/18/sea_43.pdf

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