One of the key requirements for learning in any complex endeavor is time for focused reflection following action. Looking back on goals, choices, actions, and perceptions, and comparing them to actual outcomes is the one best way to become more effective over time, and to adjust action or strategy that doesn’t deliver.<\/p>\n
This is what’s supposed to happen in staff meetings — in addition to equally essential forward-looking discussion. It’s supposed to happen in board meetings. And it would seem a useful element within any community of practice — cultural managers in a particular city, discipline, job function, or who share a common mission.<\/p>\n
In the medical professions, such reflection is a requirement, not a choice — especially when something goes terribly wrong. A sentinal event<\/a> — defined as ”any unanticipated event in a healthcare setting resulting in death or Participation is necessary by the leadership of the organization and by
\nserious physical or psychological injury to a person or persons, not
\nrelated to the natural course of the patient’s illness” — triggers an evaluation and reflective process to determine what happened, and what choices or processes might have influenced the outcome. Says the Wikipedia description:<\/p>\n
\nthe persons closely involved in the systems under review. Causal
\nfactors are analyzed, focusing on systems and processes, not individual
\nperformance. Potential improvements, called an “action plan,” are
\nidentified and implemented to decrease the likelihood of such events in
\nthe future.<\/p><\/blockquote>\n