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TheUseofReflectionDuringErrorReview1

TheImportanceofReflectioninHotWater:

ExaminingOrganizationalUseofReflectionwithErrors

HowaTransfusionMedicineService,intheevaluationofanerror,canusethepracticeofreflectionto

developstaffcompetencyasameanstoidentifynecessaryorganizationalchanges.

LornaRiach

CriticalandCreativeThinking,CCT692

ProfessorPeterTaylor

May10,2010


AnErrorasaJourney

Let’stakeamentaljourneytogether.Visualizeyourselfhavingjustdonatedbloodatalocal

blooddonorcenter.Youwererecruitedtodonatethroughmultiplee‐mails,scheduledanappointment

inyourbusyday,youtoleratedalltheverypersonalscreeningquestions,satthroughthemini‐physical

assessment,andthenfinally,enduredtheactualcollectionprocess.Notonlyhaveyougivenblood

whichisprecioustoapatient,butyou’vegivenupsomethingfairlyprecioustoyou–yourtime.You

finishupyourexperiencebyhavingyoursnackandfinallygettingdischarged;backtoreality.Even

thoughitwasahassle,youfeelprettygoodaboutwhatyoudid.Afterall,givingthe“giftoflife”is

prettyspecialandselfless.

Now,imaginethatafterallofthat,yourdonationwasn’tactuallyused.Notbecausethere

wasn’tapatientsickenoughtoneedit;infact,there’sagreatnumberofpatientswhoneedyourblood.

Notbecauseatestresultindicatedyourbloodcouldn’tbeused;infact,yourbloodscreenedacceptable

andsafefortransfusion.Itturnsout‐yourdonationwasn’tusedbecauseofanerrormadeinthe

collectionprocess,suchasincompleteornotperformedqualitycontrol,impropereligibilityorincorrect

collectionprocedures.Whatdoyouthinkthen?Maybeyouthinkofthelosstothepatientinneed;

maybeyouthinkofallthetimeyouspentinthedonationprocess.Whatifthiserrorposedariskto

yourhealthorsafety,ortotherecipient?And,whatifyouknewthefacilityhadmadethiserrorinthe

past,andyettheerrorrepeated?Wouldthisimpactyouraltruism?Ifyouknewthis,wouldyoudonate

again?

Suchwouldbethethoughtsofadonorwhowasinformedoferrorsinabloodcollectionfacility.

Therefore,sucharemythoughtsintheTransfusionMedicineService(TMS)whereIwork.Partofmy

obligationsasQualityAssurance(QA)ManageristhatIaminvolvedwhenanerrorhasoccurredtolead

areview.Aspartofthereview,weevaluatetheerrorandidentifytherootcause(s),assesstheimpact


oftheoutcome,reviewtheprocess(AKAsystem)forchangestopreventreoccurrence,andidentify

opportunitiesforchangesthatmaketheprocessbetter.

Fromthetimetheerrorisidentified,tothetimeweactuallyimplementachange,1‐6weeks

(sometimesmore)canelapse.But,we’renotevendoneatimplementation.Wethenhavetowaitand

gobacktoverifytheeffectivenessofthechange.Didithelpreducetheriskofharmorreoccurrence?If

so,ourjobisdone.Ifnot,weneedtotakefurtheractiontorectify.Kempdescribedthisprocessin

2005,referredtoasPlan,Do,Check,Act(PDCA),anditisthehallmarkcycleoferrorreviewseenin

manyTMSfacilities.KempsummarizesPDCAastheskillto“…planworkthatsolvesaproblem,dothat

work,checktoseeif[ifanorganization]gottheresults[they]wanted,andthentakeactiontomakeuse

ofwhat[they]learned”(p.33).

Sometimes,wefindoutthatmaybethechangewasn’teffectiveatall.Wemayevenfindout

thatthechangeneveractually“stuck”inthefirstplace.Hoursandhoursofwork,planning,

communicating,and…itturnsoutthatitwasnevertrulyacceptedbythestaff,soofcourseitwasn’t

effective.Howcoulditbeeffectiveifnothingreallychangedintheirpractice?Byperformingrootcause

analysis,Kemp(2005)describedthatthegoalisto“…usetheinformationabouterrorstogobackand

changetheprocesssotheerrorwon’thappenagain”(p.82).Ifwe’regoingthroughtherootcause

analysisprocess,andidentifyingchanges‐whydoesn’titalwayswork?

It’sduringthetimesthatIstarttothinkandwonder.Ithinkofthesafetyfortherecipient,and

thedonor;butIalsothinkofallthetimepeoplegivewhentheydonated;theconstantneedforblood

donorstofilltheneedforblood;and(selfishly)eventhetimeIputintoreviewtheerror.AndIfeel

frustrated.AndIwonderwhyitdidn’twork.Butbythen,I’mlikelytoldofanothererrorthathas

occurred…andI’moffandrunning!Notimetofeelfrustrated;notimetowonder.Backtogathering


who,what,why,where,when…backtoplanningchanges,backtoimplementing…backtoattemptingthe

PDCAcycle.However,sometimesitfeelslikealessthaneffectivecycle.

Andso,ourjourneyendsinthehereandnow.Butitbegsthequestion‐what’sreallygoingon

here?FormuchofmytimeinQA,Ihavethought–whydowemakeerrors?WhatcanwedotoNOT

makemistakesandmakeourprocesses“errorprone”tostaff?I’veeventhought‐whycan’tstaffJUST

FOLLOWTHEStandardOperatingProcedure(SOP)thewayit’swritten?Itwasonlythroughthe

researchofthispaperthatmylineofquestioningshiftedandinsteadIbeganasking–whyaren’twe

collectivelylearningfromourmistakes?Whatcanwedo,individuallyandasanorganization,toreview

anerrorandactuallypromotelearningasaresult?And,whycan’tthatlearningextendtoothersinour

team,asacatalysttosmartchangesthataretrulylearningmomentssharedbystaff?

WhatcanIlearnaboutpracticesthatsupportacultureoforganizationallearninginthe

evaluationofanerror?Specifically,howcanthepracticesofindividualandgroupreflectionbestbe

utilizedtodevelopcompetencyandhelpidentifychangesasaresultofanerror?

Iwillexploretheabovequestionsthroughoutthispaperandpresentthefollowingproposalfor

anideathatcombinesdifferentmodelsforreflectionintoonethataTMSmayperformforerrorreview:

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WhyMe?WhyErrors?WhyisthischallenginginaTMS?

BeforeImoveon,it’simportanttotakeamomentandreflectonwhyI’mtrulyvestedinthis

subject.TogetagoodunderstandingofwhythingshappeninmyTMS,it’simportanttoknowwhoelse

issupervisingit,outsideofourfacility.AsMotschman(1999)describes–becauseaTMSdealswith

humanbloodwhichfallsundertheFoodandDrugAdministration(FDA)definitionofabiologic,atthe

largestregulatory(governmental/federal)leveltheFDAsetsrulesbywhichaTMSmustoperate.

Additionally,smallerlayers(yet,notlessrigorous)ofvolunteeraccreditationagenciessetregulations,

liketheAmericanAssociationofBloodBanks(withaprimaryfocusonbloodcollectionandtransfusion),

ortheJointCommission(whichensuressafepracticesareinplaceforpatients,includingtheactivities

thattakeplaceinaTMS)thataTMSmustalsofollow(p.165).

Eachoftheseagencieshastheirownsetofregulationsorstandards.And,eachbelievesthey

areofferingthebestapproachtopatientordonorsafety;forthepurposesofthispaper,thesebeliefs

willnotbechallenged.EachagencyperformsunannouncedinspectionsofaTMSinwhichtheyarefree

toinvestigateandinspectallaspectsofourprocessesandourrecords.Whytheseagenciesare

importantforthispaperisbecausetheyprovide“rules”intheformofmultiplesetsofstandardsby

whichourTMSmustinterpretandestablishourownSOP’s,processes,andpractices.Motschman

(1999)elaboratesspecificallyontheFDArequirementsthataTMShave“…proceduresforreview,

evaluation,investigation,andcorrectionofmanufacturingerrorsandaccidents…inplaceandexactly

followed”(p.165).Therefore,aTMShasaconsistentoutsidemanagerthatwereporttoinadditionto

ourinternalfacilityleadership.

Whileeachsetofregulations/standardsisslightlydifferentintheirperspective,thereisa

commonthreadtoallofthem–theyrequirethataTMSoperatewithinaqualitysystemstructure,and


havesomefunctionofQApresent.“Qualitysystem”and“QA”canbesometimessubjectiveterms,but

n2005,KempsummedupQAencompassing:

…activitiesoutsidetherealmofcheckingandqualitycontrol.[It]includescross‐departmentalcommunicationaboutquality,communicationwithvendors,redesignoftheproductorprocesstopreventerror,andavarietyofauditprocessestomakesurethatworkandmanagementarebeingdonetostandardsorinaccordancewithbestpractices.(p78)

QAactivitiesarethereforeperformedtoenforceintegrityinworkprocessesandhaveanonus

offindingweaknesses/errorsontheoperationssidewiththeintentionofprocessimprovement.

BecauseQAisnotapartofoperations(i.e.,notaccountable),QAhelpsremoveanyresponsibilitybias.

BecauseQAisnotresponsiblefortheproductivityofproceduresperformedinoperations,theydonot

havethebiaswhichmayprohibitthemfromidentifyingandreportingerrors.Amanageroremployeein

operationsmayfeelpressurethatreportingerrorsisapoorreflectiononthemortheiroperations,and

thereforehasanincentivetohideorcoveruperrors.ThebalanceneededbetweenoperationsandQA

wasillustratedbyMoore(2003)andcanbeseenintheFigure1:TheBalanceBetweenQAand

OperationsWithinanOrganization,followingthispaper.IntheTMSwhereIwork,Iamtheonlyperson

inQA,andIuseourqualitysystemtoschedule,monitorandreportonmanydifferentactivitiesto

ensureastateofcontrolinourprocesses.Ireporttoaleadershipteam,whothenreportupthechain‐

of‐commandwithinthehospitalorganization.Therefore,Ihaveavestedinterestinourerrorsanderror

reviewprocess.

IdentifyingErrors–IncludingHumanError

ForaTMStomaintainastateofcontrolinitsprocesses,theirqualitysystemmustincludeQA

activitiesthatgolookingfortrouble(errors)beforetroublefindsthem.Sometimestroubleisfoundon

ourown(viaaninternaldiscovery);sometimestroubleisfoundduringaninspection(viaanexternal

discovery.)Withoutdoubt,internaldiscoveryisfarbetterthanexternal.Kemp(2005)pointsoutthatto

reallyfindtroubleinternally,it’snecessarythatallstaff(notonlyQAandmanagers)knowwhatitlooks


like(i.e.,developanerrorsensitivity)sothattheycanpreventitbeforeitimpactsthepatient/donor

andcausesasafetyissue,orsotheycanreportitonceitoccurred(p.52).

Harteis,Bauer,andGruber(2008)studiedthissensitivitylevelbyevaluatingworker’sand

manager’sinterpretationoferrorsituations.Theirstudyshowedthatwhilethereisadifferenceinthe

interpretationsoftheerrors,therewasnotalargedifferenceintheidentificationoferrorsbetweenthe

twogroups.Theywentontoexplainthatthereweredifferencesininterpretationbecausethe

managerssawtheopportunitytolearnmorereadilythantheemployees,eventhoughbothgroups

couldidentifyanerror(p227).This,then,evidencesthepossibilitythatallerrorscanbeidentifiedand

thereforereportedbyemployees,eveniftheinterpretationforlearningisunknownatthetime.

Errorsofallsizesareimportantforafacilitytoreportandevaluate,andinanopen‐reporting

environmentstaffneedstofeelcomfortabletoreportthem.Toreallyfosteremployeereporting,the

errorsystemmuststandwithanon‐punitivespineasitssupport.AccordingtoMoore&Foss(2003),

thisisimportantbecause“nothingwilldryupthefundofinformationonerrorsasquicklyasthefearof

retribution”(p.1518).ThismeansinaTMS,employeesmustbelievethatdiscoveringerrorsislike

findinganopportunityforimprovementandlearning,andnotseethemasfailures.

Ofcourse,it’slogicaltowonder–caneveryerrorreallybeidentifiedasanopportunityfor

learning?Couldn’tsomejustbechalkeduptohumanfailing?WhenIreflectedonmyownpersonal

experienceinaTMS,thetraininghadalwaysbeenperformedusingerror‐avoidancetechniques.Avoid

theerrorbydoingexactlywhattheSOPinstructsmetodo.FollowtheSOP,andI’llbeerror‐free!(Orat

leastI’mfreefromaccountabilityifIfollowedtheSOP,buttheSOPwaswrong,andImadeanerror!)

Thisleadstoa“followanddon’tquestion”mentality;thisdoesnotpromotecriticalthinkingin

employees.


Thisexperience,Ibelieve,wasthestemformyoriginalthoughtsabouterrors,wonderingwhy

peoplemakeerrors,andwonderingwhytheycan’tjustdoitright?Ithadbeen,insomesense,

indoctrinatedintomethroughallmyyearsofeducationandtraining!Thatbeingsaid,Itruly

understandandrespectthatSOP’sinaTMSneedtobedetailedtoreducevariationinpractice.

However,SOP’sdon’trepresenttherealworldallthetime;theytrytobewrittentocovertherealworld

mostofthetime.Intherealworld‐walkintoanyTMSandyou’llseestaffmulti‐tasking,respondingto

needsofcustomers,donorsandpatients,andreactingtothesocialenvironmentthey’rein.SOP’saren’t

writtentoincludehumansocialinteractions,disruptions,andtheunpredictablemomentsthatoccurin

anygivenday,mostofthetime.

Indeed,humansareunpredictableattimes,andoneofthemostunderstandablethreadsto

humanityisthatwearecapableofmakingmistakes.AndasBauerandMulder(2007)described,

humansworkingindynamicworkplacesareevenmorepronetomakingerrors,becausein“work

environments,wherechangesinrelevantknowledge,proceduresandmethodsarefrequent,employees

havetoadaptcontinually.Therefore,thereisanincreasedlikelihoodoferrorstooccur”(p121).

AccordingtoBauerandMulder(2007)organizationsneedsystemsandprocessesplannedtominimize

thechanceofanerroroccurring,butalsostrongenoughtotolerateanerror(bycatchingitfroma

secondarysource)beforeithasthechancetocauseharm(p.122).

UsingErrorsasLearningOpportunities

Furtheringthisthoughtoferrors,in2007BauerandMulderperformedastudyaboutthetypes

oferrorsfoundinhealthcareandproclaimedthattheycouldbelargelyclassifiedintotwocategories–

slipsandlapses(SL),andknowledge‐andrule‐basederrors(KRE)(p123).RefertotheAppendix1‐

ClassificationofHumanErrorsforfurtherdescriptions.BauerandMulder(2007)placedtheargument

thatSL’sareexamplesofsystemerrorsinwhichtheprocess,procedureorhand‐offsareincomplete,


thereforethesystemneededevaluationasitsettheindividualsuptofail;andKRE’swereexamplesof

errorsinwhichindividualandgrouplearningcouldoccur(p.123).

Reviewingerrorsexclusivelyas“systemerrors”wasaconsistentthemeduringtheresearchfor

thispaper.And,Ihavepersonallyattendedprofessionaleducationalconferencesinwhichthestresson

errormanagementwasthattheerrorwasalwaysduetoasystemerror,andneveranindividual/human

error.WhileBauerandMulder(2007)admitthereismerittothisconcept,theytakeaimatthe“one

sizefitsall”classificationforerrors.Theybelievethattosolelyrelyonthisduringerrormanagement

“disregardsthepotentialofindividualdevelopmentinreducingspecifictypesoferror.[Andit]further

neglectsthecontributionoferrorstoindividualprofessionaldevelopmentandteamlearning”(p122).

Theyprovidetheconceptthatwhileanoutcomeoferrorsistocorrecttheeventandprevent

reoccurrence,andtoprovideopportunitiesforindividuallearning,itcanalsobeusedforgrouplearning

andevengroupdevelopment.

Learningfromerrors,asstatedbyBauerandMulder(2007),isaconstructivistactivity–

wherebytheindividuallearnsbyprocessingtheinformationandcreatingthelearning(i.e.,engagingin

it)(p.131).Insteadoftraditionaltrainingmethodswhichrelyontheindividualtolearnpassivelyonly

whattodo(viaerror‐avoidancetrainingmethods),whenlearningfromanerrortheindividualislearning

howtodosomethingbylearningwhatnottodo.In2008,Harteis,Bauer,andGruberdescribedthis

typeoflearningasnegativeknowledge.Theyincludedintheirdiscussionofnegativeknowledgethatit,

combinedwithtraditionalformsoflearning,helps“individualstounderstandthenatureofacomplex

world”(p.225).Throughlearningvianegativeknowledgeweareallowedtomakeassociationsand

drawconnectionsthatwouldnototherwisebeevidentfromtraditionallearningalone(p.225).

Totrulyallownegativeknowledgetobeatitsmosteffective,Harteis,Bauer,andGruber(2008)

proposethatatwo‐stagecyclebeused:thefirstpartofthecyclebeingtheuseofreflection,followedby


thesecondwhichincludessharingthelessonslearnedwithallintheorganization(p.225).Whilethis

seemslikearelativelysimple(two‐step)process,theyrealisticallyleverageitstatingtheirdoubts“…to

whatextentmistakesoccurringineverydayworkarereallyreflectedonattheindividualor

organizationallevels,inordertoprovideopportunitiesforlearning”(p225).Therefore,whileatwo‐

stepprocessmayseemrelativelyeasytounderstand,it’sobviouslymorechallengingtoactuallyuse.

ADefinitionofReflection

Beforedescribingtheuseofreflection,it’sworthdelvingdeeperintodefiningwhatreflection

reallyis,anyway.HØyrupin1999deliversaconceptofreflectionbyfirstwarningreaderstonotthinkof

reflectionasasolitarycognitive(introspective)activity.Hebroadenstheconceptofreflectionand

suggeststhatadistinctionisneededbetweenreflectionand“criticalreflection”,andgoesontoaddthat

thereareevendifferentlevelsofreflection:individual,interactive,andorganizational(p.443).HØyrup

(1999)goesontofurtherthatwhilereflectioncanleadustothinkaboutasingularsituationbyposing

questions,criticalreflectionrequiresustoexpandbeyondthatsingularsituation.Itrequiresustoask

morequestions,exploreourassumptions,defineourbeliefsbyquestioningthemeaningofwhatwedo,

andmoreimportantlysometimes‐whywedoit–withthespiritthatindoingso,adeeperlearningwill

takeplace(p.445,448).Thisdeeperlearningtranslatesintocompetencyandcomprehensive

development.

ThisdescriptionofreflectionwasechoedbyGartmeier,Kipfmueller,Heid,andGruberin2008

whentheyconcurredthatcriticalreflectionwasneededatwork,butaddedthatreflectioncouldbe

activity‐oriented,andsocial.Theygoontocastcriticalreflectioninabroad(andsimpler)lightas

somethingwiththepotentialtohighlightthecomplexitiesthatexistinaworkplaceenvironment(p.6).

Theycontinuethatwithoutthecriticalreflectionaspect,thepotentialthatispossible(suchas

professionalcompetency,grouplearning,andchange)wouldbelost(p.7).Itiswithinthesetwo


representationsanddefinitionsofreflectionthatIcouldbegintorespectandunderstandthetrue

potentialofsuccessfullyimplementingthistool.However,aswithanyimplementation,ittoocancome

withitsownsetofchallenges.

AnOrganizationalPerspectiveofReflection

Foranorganizationtoconsiderachangetousingreflection,it’simportantthattoevaluate

whetherit’s“worthit”fororganizationstomakethechangeinthefirstplace.In1996,Daudelin

describedbenefitsoftheorganizationaluseofreflectionwhichincludedthefactthatit:

• generatedafeelingofcamaraderie,trust,andfellowshipduringgroupreflection;• allowedforaslowingofthingsforamoment(stoppingtheactionmode,andinitiatingthe

reflectionmode)toevaluatethesituationcollectively;and• allowedforgrouplearningtotranspirebysharingpersonalinsightsanddilemmas(p.45‐46).

Gartmeier,Kipfmueller,Heid,andGrubersupportedthisthoughtfurther,asin2008,theydescribed

theoutcomeofreflectionasawayto:

• increaselearningpotential;• allowlearningtooccurviaexperientialknowledge;and• fosterprofessionaldevelopmentandcompetence(p1‐11).

So,clearlytherearebenefitstoperformingreflectionatwork–especiallyintheevaluationofan

error,whenanorganizationhasarealreasontoreflect.And,reflectionisn’texactlyanewtool‐given

thefactithashistorictiesbacktothetimeofSocrates,it’sprobablyoneoftheoldestbusinesstools

available.So,whythen,isn’titusedmorefrequentlyinorganizations?

Daudelinprovidedapossibleexplanationin1996bystating“…managershavealwaysplaceda

highervalueonactionthanreflection”(p.37).So,inotherwords,theslowingdowntimethatittakes

toperformthereflectionisseenasloss‐of‐productive‐timethatcouldbespent“doingsomething”

productive(p.37).Thisthoughtcertainlyechoestheaction‐oriented,taskcompletingenvironmentof

anyTMSwhereI’veworked,whichmayhelpshedlightonsomechallengesI’llface.


AninterestingargumentchallengingtheuseofreflectionwaspresentedbyIxerin1999around

theuseofreflectioninthathepresentsanargumentthatitrequireseveryoneinvolvedtohavethe

sameunderstandingofreflection.Ixersuggeststhatwhenonestartsreflecting,theywouldinessence

needto“stopworking”,becausetheyneedtostopallaction.Hesupportsthatthoughtbyadding

duringreflectiontheemployeemustrelyontacitknowledgeiftheyarecontinuingtoworkwhile

beginningareflectionprocess;thereforeanemployeeisn’tcapabletobeinbothworldsatonce(p.

518).However,Daudelin(1996)providesresearchthatsupportstheuseofreflectiontofoster

productivityandsuggeststhatasmallinvestmentoftimetogetthelargestrewardfromreflective

practice(p.47).And,sincethefocusofthispaperistheuseofreflectioninerrorreview–wecan

acknowledgeIxer’sargument,andleaveitunchallenged,sinceinthissetting,actionhasstopped

anyway.

Therefore,whenthinkingaboutusingreflectionatwork,anorganizationmustacknowledgethe

challengesitmaypresent.AsstatedbyGartmeier,Kipfmueller,Heid,andGruber(2008),thelargest

challengewouldhavetobeifreflectionisnotacceptedbythestaffinvolved.This,understandably,

wouldcurtailthepotentialofitsuseandtherefore,reducethepossibilities.Anotherchallengethey

presentedisifanorganizationhasnon‐reflective,butproductive,employees(ormanagers)–sothatthe

useofreflectionwillnotbeendorsedorhaveitspotentialunderstood,(eventhoughtheremaystillbea

benefitfromit)(p.7).Inaddition,in2000Morrisonprovidedanotherchallengeof“organizational

silence”whichcanpreventanorganizationfromobtainingacultureoflearning.Organizationalsilence

occurswhenmanagersthemselveshaveafearofnegativefeedback,andstatedthatwhenmanagers

viewdifferingopinionsfromsubordinates,theycanfeelthreatened(p.708).Thisleadstoathought

processthatdisagreementisalways“bad”,andthatunityis“good”–evenifthisunityisjustsilent

following(p.710).ApersonalchallengethatIcanaddisthataninexperiencedfacilitatorcouldalterthe


outcomeandacceptanceofreflectionatwork,aswell,iftheprocesshasaroughinductionperiod;

therefore,employeeswhowereacceptingmaychangetheirmind.

Itisnoteworthytoacceptthatthesechallengesparallelthechallengeofimplementingalmost

anychangeinaworkplace;theyarenotspecifictoreflection.Withoutthebuy‐inoracceptanceofthe

staffinvolved,theabilitytoseesomeimprovementfromthechange(eitherinproductivityormorale)–

then,changeisnotpossible.Thisisanappropriateandimportantchallengetoovercomebutthefocus

ofthispaperwasintheresearchofusingreflection,notintheimplementationofreflection.Forthis

reason,thesechallengesareacknowledged,butwillnotbepursuedatthistime.

I’lladmit,it’sbeenchallengingformetonotthinkofreflectionasasolitaryactivity,givenmy

ownassumptionsthatreflectionrequiredsittingquietly,beingpensive,andponderingthroughwriting;

allthingswhichhaveneverbeenpartofmynature.However,intheresearchofthispaperIwas

exposedtoexamplesofreflectionwhichdemonstratedthesocialnatureinwhichitcouldexist.

Daudelin(1996)providedconcreteexamplesofreflectiveactivitiesthatcanbedoneeitherindividually

orinagroup.Theseallwereaimedatathoughtfulexaminationofasubject(i.e.,anerror)withagoal

ofidentifyinglearningopportunities,connections,andareasforgrowth.Theseexamplescanbeseenin

Appendix2:ExamplesofReflectiveActivities.Itwaseye‐openingtomethatDaudelinonlylistsjournal

writingasoneofsixexamplesofsolitaryreflectionpractice,andthatatleastfourofthegroupactivities

couldbewellutilizedinerrorreviewsessions(problem‐solvingmeetings,projectreviewsessions,

informaldiscussionswithcolleagues,andfeedbackdiscussions)(p.42).

FacilitatingReflectionUsingORIDQuestioning


Attheheartofreflectionisthewell‐definedandwell‐directedsetofquestionswhichleadstoa

dialogue.Thinkingabout“questioningthestaff”maybringtomindimagesofalongtable,whichonone

sidesits“themanagers”,andontheothersidesits“theemployees.”Thelineofdifferentiationclearly

drawn–andthequestionsarecomingfromoneside,responsesfromtheother.Thisalmostinherently

impliesthatthemanagersknowwhatthe“right”answeris,andtheyaretestingthestafftoseeifthey

canstateit.Thisdidnotalignitselfwithmyimageofgroupreflection,however.Stanfield(1997)

providesapracticalguidetobreakingthemoldofacrossthelinequestioning,andinsteadpresents

groupreflectionintheformatofa“focusedconversation”(p.17.)

AsdescribedbyStanfield(1997),afocusedconversationisamethodusingtheORIDformat

(objective,reflective,interpretive,anddecisional.)Afacilitatorleadsthegroupthroughtheprocessby

askingthequestions–andpreventingthegroupfromrushingtothedecisionsuntiltheyhavepassed

throughallphases.Thisprocessisdesignedtoopenthethinkingofthegroupsothatgroupinputis

usedto,intheend,makeagroupdecision.Iseethisbeinginvaluableduringtheevaluationofanerror,

butIalsoseeitbeinginvaluableasanaddedparttotheeffectivenesscheckinourTMS,asawayofre‐

circlingbackwiththestafftoidentifyhowthechangeisaffectingthem.Thiscanbeamechanismto

eitherhelpidentifythechallengesorsuccessofthechanges.ForanexampleoftheORIDformat,please

seeAppendix3:ExamplesofaFocusedConversationPlan,usingORIDTechnique.

InthinkingaboutusingORIDforreviewoferrorsatwork,it’sunderstoodthatthiswillrequire

stafftotalkopenlyabouttheirerrors,andindoingsocouldleadtothemfeelingsofjudgmentand

vulnerability.Therefore,thefacilitatormustnotcomefromaplaceofjudgment.Cannonand

Edmondson(2001)describedthat“poorhandlingofconflictcanleadtoahostileenvironmentinwhich

trustandinterpersonalrelationshipsbreakdown.Undertheseconditions,fearofbeingridiculedor

blamed…maykeeppeoplefromdiscussingtheirfailuresordisagreements”(p.165).Withproper


handling,however,theygoontodescribethatdeeperlearningcanoccur(p.5).Thisapproachmustnot

onlyliveatamanagerslevel,itreallymustcomefromtheorganizationallevelandbesupportedand

exemplifiedatthemanagerlevel.

ReflectionasanIntegralPartofanOrganizationalCultureofLearning

Alloftheactivitydescribedthusfarhasbeenattheindividuallevel–however,it’simportantto

rememberthattheindividualactivitymustbesupportedattheorganizationallevel.In2001,Billett

describedcooperationbetweentheindividualandtheorganizationthatmustexistforemployee

learningtooccur.Billettdescribesthattheindividualmustpossesstheengagementanddesiretolearn,

buttheorganizationmustprovidetheopportunitytogainnewknowledgeviaactivitiesthatthe

individualsexperienceintheirevery‐dayactivities(p.210).Occasionally,however,theindividualand

theorganizationfailcooperate.RefertoAppendix4:FactorsthatInfluenceWorkplaceLearningforalist

ofinfluencingfactorsthatbreakdownthecooperation(p.210).WhileBilletdoesnotspecifically

referenceerrors,thefactorspresentedcanbeassimilatedbyafacilityattemptingtolearnfromerrors.

Forexample,it’spossiblethatmanagershaveassumptionsaboutanemployee’scompetencywhenthey

areinvolvedinanerrorthatcouldaffecthowthemanagerprovidestheopportunityforthemtolearn.

Organizationsmustsupportthepracticeofreflectioninorderforittobeusedattheindividual

levelindepartments.CannonandEdmondon(2001)citeachallengeofanorganizationalcultureof

learningfromerrorsisthatvisionstatements,missions,orgoalsoftheorganizationcanliveinonelayer

oftheorganization,whilemanagersandemployeesliveonanotherlayer.Ifthemanagerwhoperforms

astaffmember’sannualevaluationviewserrorsasafailuretomeettheirjobrequirement,then

understandably,staffwillnotfeelsecureinreportingtheirerrors(p.167).Intheirresearch,theyfound

thatteamswithinanorganizationcanhavevaryingunderstandingsandbeliefsaboutfailure(p.173).

Thishelpstoprovideanunderstandingabouttheuphillbattletoreallygetuniformityand


understandingwithinanorganization,andwhatitwilltaketoreallygetaworkplacetoacceptthe

changenotonlyasanoutcomeofanerror,butalsothechangetowardusingreflectioninerrorreview.

Tocombatthis,CannonandEdmondon(2001)proposeseveralantecedentsthatmustbein

place.Theseantecedentsincludethefactthatmanagersmustbeseenandactascoachesorleaders;

thataworkgrouphaveacleardirectionwithasharedexpectedoutcome(sothatfailurescanbe

identifiedandunderstood);andthatallinthegroupfeelsupportedwithaccesstoresourcesand

information,tohelpthemfeelrespected.Theseantecedentswillhelpestablishasharedbeliefabout

failureanderrors,sothatthegroupcanmovebeyondfearandintimidationandheadtowardslearning

thatleadstorealchange(p.168‐169).

LearningfromErrorsasaMeanstoIdentifyChangeandDevelopCompetency

Learningfromerrorsintheworkplacehighlightsthesocialinteractionsandemotionsinvolved

aswell.BauerandMulder(2007)suggestthaterrorsatworkrequiretwostronginfluencersinstaffas

determinatesforsuccessfullearningwillbe.Theinfluencersaredeliberateself‐regulatedlearning

ability,andthestaffuseofnegativeemotions(p.130).Thesetwofactorswillheavilyinfluencewhether

learningcanactuallybeachievedinerrorreview.

Deliberateself‐regulatedlearningabilityispresentedbyBaurandMulder(2007)asameansto

achieveandacceptchangeasaresultofanerror(p.130).Thisallowstheworkerstoacquirenew

cognitiveknowledgetochangetheirbehavior(orunderstanding)whenpresentedwiththesituationin

thefuture.Thisimpliesawillingnesstochangeandcanstarttobridgethethoughtthatlearningisa

formofchange;thereforechangeisaformoflearning(p.130).

Negativeemotionsareanimportantinfluencerforlearningatwork,asBauerandMulder(2007)

state:


Usually,negativeemotionssuchasembarrassment,shame,guilt,fearorthefeelingofincompetencyareassumedtobeinhibitingforopen‐errorcommunicationandlearningfromerrors.However,severalsubjectsinthestudyclaimedthatnegativeemotionscanhaveafosteringaswellasinhibitingeffectsforlearning;negativeemotions(e.g.guilt;fearofpunishment)canleadtoconditioning,sothattheerrorepisodeisrememberedinsimilarsituationsandonehasthepossibilitytoavoidtheerror.(p130)

Together,thesetwofactorsplayanimportantpartofthesocially‐constructedlearning

“classroom”thatistheworkplace.BaurandMulder(2007)summarizedthefollowingtwoconcepts

regardinglearningfromerrors:

• First,manyemployeesdidn’tconnectlearningfromerrorsaslearning,sincethelearningwasexperientialandlackedtheprogressiveandformalfeeloftheirtraining.

• Andsecond,theyidentifiedthattheworkplaceprovidedalearningatmospherethatrequiredsocialexchange,andtherefore,learningfromerrorsallowsforgrouplearning(p.131).

Bauer(2007)alsoaffirmedthaterrorsareprimefodderforlearningbecausetheyprovidea

changefromtheopportunitytoquestiontheroutineperformanceoftasks.Becauseanindividualcan

learnfromtheerror,thisindividualcanthengoontosharetheirexperienceandgetdifferent

perspectivefromtheircoworkersonthesituation,causesandthechangesthatareneeded(p.684).

ThissharinginformationwasalsoreferencedbyHarteis,BauerandGruberin2008asthesecondphase

requiredforlearningvianegativeknowledge(p.225).Bauer(2007)includedanargumentforgroup

learningbecauseobtainingmultipleperspectivesonanerrorwillexpandanindividual’scapacityfor

learning;thiswillthenpromoteareciprocalbenefitfortheircoworkerssothegroupcanprovideinput

forchangesneeded.This,then,promotesgroupcompetencydevelopmentandgroupacceptanceof

change(p.684).

PracticalConceptofReflectioninaTMS

Daudelin(1996)wasoneoftheearliestauthorsinmyresearchtodescribeareflection“cycle”

byrelatingphasesthatthereflectionprocesspassesthrough.Thiswashelpfulindevelopingmyimage

ofreflection,butit’simportanttonotethatthatthisisjustonerepresentationofreflection,anditdoes


notintendtosignifythatreflectionmustfollowthislikeadirectproceduralpath.Infact,thismaybe

thehardestpartforaTMStoendureinareflectionprocess–thereisnoSOPforreflection!Gartmeier,

Kipfmueller,Heid,andGruber(2008)actuallyarguedagainstaschematicrepresentationofreflection,

statingthatindoingso,thecomplexityofreflectionwasdiminished(becomingmoreofadestination,

insteadofanexperience)(p.5).Thatbeingsaid,asanovicetotheideaofgroupreflection,Iactually

foundvalueinDaudelin’s(1996)presentationofreflection‐forwhatitwas(andrespectedwhatit

wasn’t)‐itcanberepresentedas:

!"#$%&'(#$)*+),+(+

-").'/0

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=(&5/'$*+:>??@<+-9+AB

Usingthisasastartingpoint,there’sanopportunitytoexpandthisandincludetheaspectsof

individualandgroupreflection.IfthiswasusedintheframeofreferenceofaTMSerrorreview,itmay

presentsomethinglikethis:

!"#$%&'()*$")

+#,-+%)*$)#++-+ .

/0*$)&$"&1&"2*0)

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+#'0#4%&-$)-$)%5#)

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,0*$)4-++#4%&1#)*4%&-$ .))

=5*+#)%5#)#++-+)%-)*00)&$)

%5#)"#,*+%;#$%)'-+)

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!;,0#;#$%)

4-++#4%&1#)*4%&-$

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*$")#''#4%&1#$#77)

-')45*$3# .

>#;,)?@AAB C)/:DE)D(40#)

F*+%#&7 <)G*2#+<)*$")H+2I#+) ?@AAJ C)KL-)=%#,)M-"#0

:*2"#0&$) ?NOOP C)9#'0#4%&-$)D(40#

=%*$'&#0") ?NOOQ C)89!:)R-427#")D-$1#+7*%&-$)R-+;*%

IncombiningtheDaudelin’s(1996)reflectioncyle(p.40),Harteis,Bauer,andGruber(2008)two‐

stagecycleofreflectionfollowedsharingthelessonslearnedwithallintheorganization(p.225),but

incorporatingtheORIDformatofafocusedconversationdescribedbyStanfieldin1997thePDCAcycle


issituatedwithinareflectiveframe.Thisallowstheregulatoryrequirementsofafacilitytobemet,but

willopenthepossibilitiesforcompetencydevelopment,grouplearning,andeffectivechangebecause

reflectionincorporatesandopensthechannelsthatcanleadtorealorganizationalchange.

Conclusion

ExaminingtheuseofreflectionisasignificantandrelevanttopicformeandIfeelI’vegathered

evidenceofitspotentialinaworkplace(andevengarneredsomepersonalbenefitsalongtheway!)I

aminauniquepositioninQAtobeabletoinquireandexamineourfacility’sacceptanceofsucha

process,assuredthatwewillcontinuetomaintaincompliancewiththeregulatoryrequirementsas

needed.

Errorspresentanopportunityforlearning,andasIhavelearned–learningisaformofchange,

sochangeisaformoflearning.Therefore,errorsdohavethepotentialtobringeffectivechange–as

longasthechangeisidentifiedandacceptedbythestaffmostaffectedbyit.Ibelievethereissufficient

evidencetosupporttheconceptthatincorporatingreflectionisarealisticandachievablegoalformy

TMS.Withanerrorsystemalreadyinplace,weareinagoodpositiontoevaluateandplanan

improvement.Iacknowledgethechallengesthathavebeenidentifiedwhichmayhinderthisprocess,

butfeeltheyareobstacleswhichcanbeovercomeorganizationallyandindividually.

Myfutureareasofinterestresideintheimplementationofsuchasystemasamechanismfor

changeintheworkplace.MovingforwardwithmyCriticalandCreativeThinkingeducation,andwithin

myprofessionaldevelopmentwithmyemployer,Ilookforwardtocontinuingtheevaluationofthis

topicandmovetowardsbeingpartofsuchanexcitingpossibility.


References

Bauer,J.(2007).Workplacechangesandworkplacelearning:Advantagesofaneducationalmicro

perspective.InternationalJournalofLifelongEducation,26(6),675‐688.

Bauer,J.,&Mulder,R.H.(2007).Modellinglearningfromerrorsindailywork.LearninginHealthand

SocialCare,6(3),121‐133.

Billett,S.(2001).Learningthroughwork:Workplaceaffordancesandindividualengagement.Journalof

WorkplaceLearning,13(5),209‐214

Cannon,M.D.,&Edmondson,A.C.(2004).Failingtolearnandlearningtofail(intelligently):Howgreat

organizationsputfailuretoworktoimproveandinnovate.Boston,Mass.:

Daudelin,M.W.(1996).Learningfromexperiencethroughreflection.OrganizationalDynamics,24(3),

36‐48.

Gartmeirer,M.,Kipfmueller,S.,Heid,H.,&Gruber,H.(2008).Reflectionandprofessionalcompetence.A

studyatdynamicworkplacesinthenursingsector.No.ResearchReportNo.35).Regensberg,

Germany:UniversityofRegensberg.

Harteis,C.,Bauer,J.,&Gruber,H.(2008).Thecultureoflearningfrommistakes:Howemployeeshandle

mistakesineverydaywork.InternationalJournalofEducationalResearch,47(4),223‐231.

Hoyrup,S.(2004).Reflectionasacoreprocessinorganisationallearning.JournalofWorkplaceLearning,

16(8),442‐454.

IXER,G.(1999).There'snosuchthingasreflection.BritishJournalofSocialWork,29(4),513‐‐527.


Kemp,S.(2005).Qualitymanagementdemystified.Blacklick,OH,USA:McGraw‐HillProfessional

Publishing.

Moore,S.B.(2003).Errormanagement:Theoryandapplicationintransfusionmedicineatatertiary‐

careinstitution.ArchivesofPathologyLaboratoryMedicine,127,1517‐1522.

Morrison,E.W.(2000).Organizationalsilence:Abarriertochangeanddevelopmentinapluralistic

world.AcademyofManagement.theAcademyofManagementReview,25(4),706‐725.

Motschman,T.L.(1999).Correctiveandpreventiveaction.TransfusionScience,21(2),163‐178.

Stanfield,B.,&CanadianInstituteofCulturalAffairs.(2000).Theartoffocusedconversation:100ways

toaccessgroupwisdomintheworkplace.GabriolaIsland,B.C.:NewSocietyPublishers.


Appendixes


Figure1:TheBalanceBetweenQAandOperationsWithinanOrganization

ReproducedfromMoore,S.B.(2003).Errormanagement:Theoryandapplicationintransfusionmedicineatatertiary‐careinstitution.ArchivesofPathologyLaboratoryMedicine,127,p.1519


Appendix1:ClassificationofHumanErrors

From:Bauer,J.,&Mulder,R.H.(2007).Modelinglearningfromerrorsindailywork.LearninginHealth

andSocialCare,6(3),121‐133.

Classification DescriptionSlipsandlapses(SL) Resultingfroma“slip”or“lapse”ofmentalknowledgethatwascriticalto

achievetheintendedoutcome.Mostlikelyfromrepetitiveforgetfulnessorattentionspanlapsesthatoccurasaresultofmonotonousoroverlycumbersomeprocesses.Thesetypesoferrorsareusuallyconsidered“system”errors,asthereisnowaytoremovetherepetitivenatureoftheirtasksandthesystemshouldbebuiltstrongenoughtosupportandidentifytheiroutcomesinsubsequentprocesses.Humanscan’tlearnmuchfromthesetypesoferrors(otherthanthattheyexist)becausethecauseoftheerrorsisinherentinthesystemandnotattheresponsibilityofthehuman.

Knowledgeandrule‐basederrors(KRE)

Resultingfromawrongdecision,orinterpretation,orworkbeingperformed.Mostlikelytheresultofa“’wrongapplicationofagoodrule’,‘non‐applicationofagoodrule’,‘applicationofabadrule’,and‘deficienciesinknowledge’.(p123)”Thesetypesoferrorscanbeconsideredindividuallearningopportunitiesmoresothansystemerrorsandcanbeusedforindividualandgrouplearning.Thesearemoreeasilyunderstoodaserrorsthataredirectlycharacteristicofindividualerror,notasystemerror.Individualshavetheabilitytolearnfromtheseerrors,astheyrepresenttheinterpretiveandindividual/humanaspectofprocedureordecisionmaking.


Appendix2:ExamplesofReflectiveActivities.

Daudelin,M.W.(1996).Learningfromexperiencethroughreflection.OrganizationalDynamics,24(3),p.

42.

Examplesofsolitaryreflection:

• Spontaneousthinkingduringrhythmic,repetitive,mindlessphysicalexercise(jogging,swimming

laps,mowingthelawn)orroutinehabits(drivinganestablishedroute,showering,shaving)

• Meditation

• Prayer

• Journalwriting

• Businesswriting(prohectreports,professionalpapers,evaluations)

• Assessmentinstruments

Examplesofreflectionwithhelperorsmallgroup

• Performanceappraisaldiscussions

• Counselingsessions

• Individualorgrouptherapy

• Problem‐solvingmeetings

• Projectreviewsessions

• Informaldiscussionswithfriends/colleagues

• Interviews

• Mentoring

• Feedbackdiscussions


Appendix3:ExamplesofaFocusedConversationPlan,usingORIDTechnique.

From: Stanfield,B.,&CanadianInstituteofCulturalAffairs.(2000).Theartoffocusedconversation:100

waystoaccessgroupwisdomintheworkplace.GabriolaIsland,B.C.:NewSocietyPublishers.

FOCUSEDCONVERSATIONFORMATRationalobjectiveTolearnwhatstaffunderstandsaboutthechangeprocessinourdepartment.

ExperientialaimReconnectthestaffandthemanagersprocesstopromotechange‐readyemployees

OpeningThankyouallforcomingtoday!Weareheretogethertohaveafocusedconversationaboutourchangemanagementprocess.I’mhopingthatbyusingtherecentexamplesofchangewecanidentifywhatthegroupthinksareeffectivemethodsofchangemanagement,andperhapswhatmethodsarenotworking.Thechangeswe’llfocusonare:

1. ThenewuseofliquidcontrolswiththeHemocue2. TheremovaloftheApheresisLotNumberLog3. Theremovalofthecoldauto‐storagecoolerfortransportofcollectedproductstotheBloodBank

Foryourpreparation,Ihaveforwardedyouthreethingsforyourreview;asummaryofourcurrentchangeprocess,anexampleof3recentchanges(usingthecurrentprocess),andour“Rules”forthisconversation.So,beforewebegin,I’dliketojustensurethateveryonegotachancetoreviewtheseitems.I’dalsoliketoremindeveryonethatI’mintheroleoffacilitatortoday;I’mnotheretosolvetheissue.That,ultimately,willbetheresulttodaybyourgroup.So,withthatinmindI’lljustremindeveryonethatthebestoutcomewillbereachedifweallshareourthoughts,andI’llaskthatwebeginbyallsharingourexperiencewiththefollowingquestion:Whatpartsofthecurrentchangeprocesscaughtyourattentionthemost?Allowalltoanswer….Great,thankyou!I’llsharemythoughtsonthataswell…..Movingforward,I’llnowopentheconversationforthesesubsequentquestionstotheentiregroup.Pleasespeakloudlyenoughtothe“center”ofthetablesothateveryonecanhearyou.

Continuedonnextpage;


ObjectiveQuestions ReflectiveQuestions InterpretiveQuestions DecisionalQuestions• Howwereyoumadeawareofthe3changes?

• WhataretheresponsibilitiesoftheTMSstaffregardingchanges?

• WhataretheresponsibilitiesoftheTMSMgtregardingchanges?

• Werethereanychangesthatyouweremadeawareofaftertheywereimplemented?

• Howdidyoufeelwhenlearningabouteachofthechanges?

• Describehow/whatyoufeelwhenyouheartheword“change?”

• Whatdoyouthinkismissingfromourchangecontrolprocess?

• Whydoyouthinkourdepartmentstruggleswithimplementingchange?

• Whatcanwedotomakechangemoreeffective?

• Whatchangesareneededinthecommunicationandsharedresponsibilitiesintheimplementation?

Time(min)5‐7

5‐7 10‐15 10‐15

ClosingThankyoutoeveryoneforparticipatinginthegrouptoday.We’vemadesomegroupdecisionsthatrequiresomeaction.Beforewedepart,let’sgooverwhatwe’vedecidedtodoandassignwhowillberesponsibleandwhenitwillbecompleted.Thegatheredinformationwillbesharedwiththisgroupagainviaemailandthenwewillre‐grouponefinaltimetodeterminehowtomoveforwardwithourdecisions.Inaddition,wecanallbethinkingaboutwhatwecandointhefuturetocheckinortestwhetherourgroupdecisionswereabenefittothedepartment.Thanksagainforyourtime,let’sclosebyallstatingonethingthatwegotoutoftoday’smeetingthatwecanusetokeepourmomentumgoing…


Appendix4:FactorsthatInfluenceWorkplaceLearning

From:Billett,S.(2001).Learningthroughwork:Workplaceaffordancesandindividualengagement.

JournalofWorkplaceLearning,13(5),p.210.

TypeofFactor Description Example

Organizational • Perceptionsofindividuals’competence

• Race• Statusofwork• Employmentstatus• Workplacedemarcations• Personalrelations,workplacecliques

andaffiliations

Basedonthehistoricalperformanceofanemployeeinaproject,themanagerdoesn’tconsiderorselectanemployeetoparticipateinafutureproject–eventhoughtheformerandcurrentprojectmayrequiredifferentskillsetsthattheemployeecouldhavestrengthsorweaknesses.

Individual • “Newcomers”or“old‐timers”• Fullorpart‐timeworkers• Teamswithdifferentrolesand

standingintheworkplace• Individualspersonalandvocational

goals• Amonginstitutionalized

arrangementssuchasthoserepresentingworkers,supervisorormanagers

Parttimeemployeedoesn’thaveaccesstoanewprojectthatwillallowlearningbecausetheirscheduledoesn’tallowthemtoattendallofthemeetings.Anemployeewhoisinschoolpursuingadegreeisnotincludedinaprojectbecausetheyareconsideredtonotbe“committed”totheirworkenvironment.Employeeswithlessthanayearofexperienceisnotincludedinaprojectbecausetheyarenotconsideredtohaveexperiencethatwillbevaluedintheproject.

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