Life Esidimeni: a Fatally Flawed healthcare De-Institutionalisation Process

In 2015, the Department of Health for the province of Gauteng, South Africa, deinstitutionalized patients in need of long term health care in an effort to reduce costs. The residents were moved from an established health care facility experienced with providing the care these patients needed to non-governmental facilities. Many of these facilities were unlicensed and lacking the skills and resources needed to provide the necessary care. The project was poorly planned with inadequate notice and patients were transferred without identification, medication, or medical records. From March to June 2016, 1,712 patients were transferred; many of them were lost in the system and 144 died—most from malnutrition, abuse, or neglect. The health ombudsman investigated and released a report in February 2017, placing the blame for the tragedy on three senior leaders in the health care system. A new member of the executive council was appointed upon the release of the report. In 2018, her challenge was to determine what happened and plan changes to ensure such a tragedy would never be repeated.

The case is intended for graduate-level or executive-level courses dealing with change management, organizational development, leadership, ethics, or project management. After working through the case and assignment questions, students will be able to do the following:<ul><li> Understand the role of accountability in making ethical and responsible decisions, the importance of accountability in stakeholder management, and the consequences of a lack of accountability in organizations and during change processes.</li><li> Taking a systemic view of an organization, identify interdependent relationships and assess complex problems at the organizational level.</li><li>Analyze the importance of identified and communicated levels of accountability in a change process or project plan.</li><li> Assess the methods and effectiveness of creating a culture of accountability within an organization.</li><li> Determine effective mechanisms to ensure individuals deliver against expectations.</li></ul>

• accountability
• healthcare
• change management
• de-institutionalisation