Workshop - Learning Before, During and After
Because of the nature of the work of the Canadian International Development Agency, professionals are always on a steep learning curve, whether they are starting work on a new country program, trying to understand the intricacies of gender equity in Pakistan or working through a new contracting process. This one-day workshop is provided several times a year to increase the ability of country teams to transfer what has been learned more systematically and across traditional Agency silos. The goal of the workshop is to provide knowledge transfer skills that professionals can put to work immediately.
Patient Safety in Healthcare
This project examined the way in which leading edge healthcare systems were implementing patient safety initiatives. We interviewed the CEO or CMO of eight large hospital systems across the country. The interviews uncovered what patient safety initiatives these systems have implemented, where their next steps are, and what their needs are as they move forward. The analysis of this interview data provided a rich picture of the current state of safety in the healthcare industry.
Putting AARs to Work for Organ Donation
Working with the HRSA collaborative to increase organ donation, we introduced AARs as a way to help organ procurement teams think through their interactions with each donor family. At the collaborative learning sessions, we conducted a live demonstration of an AAR and taught teams the steps in the AAR process. Back home, AARs helped the teams improve their rate of acceptance of donors, learning from each family engagement and preparing for the next. In the past the members of these organ procurement teams had been competently carrying out their assigned role and tasks, but it was not until they came together as a team to reflect on what they were learning through their experience, that were able to speed up the learning curve. Since a patient, who could be saved by a donated organ, dies every 18 minutes in the United States, the need is great. We are honored to have played a role in this very important effort.
Company Command
One of the most exciting projects Nancy has been involved in over the last couple of years has been interacting with the team from Company Command. This professional forum is a wonderful example of how a community, that has a well-focused mission and skillful leadership, is beginning to change the culture of the U.S. Army. Nancy spent many long yet rewarding hours interviewing Company Commanders and traveling with the team as they interacted with Soldiers. This is an amazing grassroots effort that demonstrates the power of conversation. We are in awe of these soldiers and feel privileged to have played a role in their story; CompanyCommand: Unleashing the Power of the Army Profession. Click here to learn more about CompanyCommand.
A Space for Learning
Our work with the Veterans Hospital Administration (VHA) has included serving as faculty 
in their Executive Leadership Programs and consulting with the National Leadership Board to focus on issues of the spread of knowledge and policy. The VHA is on the leading edge in integrating learning and work. Across the country they are creating Learning Xchanges, places where real dialogue and learning conversations can take place. These exciting environments change the norms of teams so they can speed up the process of getting work accomplished and knowledge exchanged.
Sensemaking in Healthcare
In a large government sponsored project on patient safety, Dr. Dixon designed and facilitated sensemaking in a number of hospital microsystems. The goal of sensemaking 
was to more fully understand errors and/or near misses. As Reason explains in his Swiss cheese analogy, all errors and near misses involve many parts of the total hospital system. In this project, rather than attempting to understand and fix those parts one by one, sensemaking created a dialogue among all involved, with the goal of understanding how a specific error might have occurred from a system perspective. It is only when all players fully understand what others are doing, and why, that the system can self correct. One of the most important tools of the sensemaking meetings were Causal Trees, developed by MERS-TM and based on the Eindhoven Classification Model. For each dialogue a causal tree was displayed on a large wall chart to provide a focus for the discussion. As the group began to gain greater understanding of the event, the causal tree was added to, corrected, and became a more accurate representation of the latent and active errors in the system. Sensemaking meetings lead to empowerment among frontline staff. As one frontline worker explained, "I have learned that the mistakes I make aren't just my fault - other nurses make some of the same mistakes - and, rather than beating ourselves up, we can be proactive and make changes in the system."
