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International Forum on Quality & Safety in Healthcare Amsterdam, April 5-8, 2011 Learning from Failure

International Forum on Quality & Safety in Healthcare Amsterdam, April 5-8, 2011 Learning from Failure. M. Rashad Massoud, MD, MPH, FACP Director, USAID Health Care Improvement Project Senior Vice President, Quality and Performance Institute University Research Co. LLC.

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International Forum on Quality & Safety in Healthcare Amsterdam, April 5-8, 2011 Learning from Failure

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  1. International Forum on Quality & Safety in HealthcareAmsterdam, April 5-8, 2011Learning from Failure M. Rashad Massoud, MD, MPH, FACP Director, USAID Health Care Improvement Project Senior Vice President, Quality and Performance Institute University Research Co. LLC

  2. Question #1: What would you do?

  3. Health Care Improvement Portal www.hciproject.org Goal: Facilitate documentation and sharing of practical knowledge, best practices, tools, and implementation experiences to support improvement activities in the topic areas of interest to middle and low income countries

  4. Adding Reports to the Improvement Database

  5. Standard Evaluation System (SES) Tools

  6. Lessons from SES Field Test • Develop a few clear standards and expectations for QI teams and large-scale improvement efforts related to learning • Monitor and use these learning system standards to improve these processes at team and program levels • Continue to test strategies for sharing changes across teams and synthesizing effective changes • Link information generated with broader knowledge management efforts • Facilitate more frequent sharing among countries

  7. Question #2: What would you do?

  8. Learning System Standards QI Team: • Maintain a record of changes tested (dates and description) • Graph indicators on time series chart and annotate with changes tested regularly • Share tested changes and results within collaborative Program Level: • Maintain a record of changes tested at each site • Aggregate and analyze results of tested changes across sites • Share tested changes and results within collaborative • Share learning outside the collaborative – nationally/ globally

  9. Knowledge Management “Deep Dive” • Myths: • “Build it and they will come” • Technology can replace human interaction • Explicit vs. Implicit knowledge • “Knowledge is generated in the moment through human interaction” • Knowledge is voluntary. We cannot “make” it happen, we can “help” it happen • Collecting vs. Connecting

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