Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A saúde pública no Brasil está inserida num contexto histórico bastante complexo no que se refere ao financiamento dos serviços. As diversas formas de financiamento que tem sido criadas, alteradas e recriadas, geram muitas questões sobre sua eficiência e aplicabilidade. O Ministério da Saúde trabalha atualmente o modo de financiamento em cinco blocos para o custeio do SUS: Atenção Básica; Atenção de Média e Alta Complexidade Ambulatorial e Hospitalar; Vigilância em Saúde; Assistência Farmacêutica; Gestão do SUS. As atividades assistenciais realizadas em regime de internação hospitalar, pelos serviços públicos e privados que integram o Sistema Único de Saúde, são custeadas por meio do sistema de financiamento hospitalar, tendo como instrumento operacional o Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS) e seu formulário próprio, a Autorização de Internação Hospitalar (AIH). O Objetivo desta pesquisa é contribuir com a gestão da saúde em Roraima, à partir do estudo do financiamento de AIH no Hospital Geral de Roraima, particularmente no que se refere aos recursos utilizados nos procedimentos de média e alta complexidade. Buscase assim, fazer um levantamento das Autorizações de Internação Hospitalar, verificando o volume de recursos implicados, bem como os meios pelos quais esses procedimentos são financiados. Como resultado verificamos que o número de AIH glosadas é significante chegando perto dos 10% do total de AIH processadas no primeiro quadrimestre de 2012. Os principais motivos de glosa foram a falta de cadastro de muitos profissionais no sistema CNES (Cadastro Nacional de Estabelecimentos de Saúde) e o CBO (Cadastro Brasileiro de Ocupações) de profissionais incompatível com o procedimento realizado. Sendo assim ficou evidente um problema de gestão para reduzir o números de AIH glosadas no HGR-RR e assim contribuir para um melhor financiamento da saúde em Roraima. / Public health in Brazil is inserted in a historical context quite complex in what refers the financing of services. The various forms of financing that has been created, changed and recreated, generate many questions about its efficiency and applicability. The Ministry of Health currently works the mode financing in five blocks to fund the benefit SUS: Basic Attention; Attention of Average and Alta Complexity Ambulatorial and Hospitalar; Surveillance in Health; Pharmaceutical Assistance; SUS Management. The activities assistential performed in regime of hospitalization, by public services and Private that integrate the Sistema Único de Health, are borne by means the system of financing hospital, having as operational instrument the Hospital Information System of System Unified Health (SIH / SUS) and your form own, the Authorization of Hospitalization (AIH). The Objective this research is contribute to the knowledge of health financing in Roraima, to from the study of question in Hospital Geral de Roraima, particularly in what refers to resources used in procedures of medium and high complexity. Searching-if thus, do a lifting of Commitments of Hospitalization, checking the volume of resources implicated, well as the means by which these procedures are financed. How result we verified that the number of AIH disallowed is signifier getting close of 10% of total AIH processed in first four months of 2012. The main reasons of disallowance were lack of cadastre of many professionals in the system CNES (Nacional Cadastre of Health Establishments) and the CBO (Brasilian Occupations Cadastre) of professionals incompatible with the procedure performed. Being thus became evident a management problem to reduce the numbers AIH disallowed in HGR-RR and so contribute to a better health financing in Roraima.

Este estudo investiga a interferência de aspectos cognitivos, organizacionais e econômicos na Orientação Temporal do Gestor (OTG) de hospitais de grande porte no interior de São Paulo. A literatura prediz que OTG é influenciada por sistemas de incentivo, como o sistema de remuneração gerencial, e nessa pesquisa foi analisado outras perspectivas que impactariam nessa relação, com base em literatura contábil, econômica, de psicologia e gestão hospitalar, entretanto outros fatores poderiam impactar na OTG, tal como o desenho do contrato do gestor ex-ante, os processos empresariais, a incerteza do ambiente e tarefa, o sistema estratégico de avaliação de desempenho e a proximidade do gestor com a atividade fim. O estudo foi realizado com 18 gestores de 5 hospitais e 1 operadora, analisando os fatores que impactam na realização de tarefas e tomadas de decisões gerenciais, com foco em diferenciar as atividades de curto e longo prazo e quais os direcionadores que os fazem focar no resultado de curto ou longo prazo. Os dados foram obtidos por meio de entrevistas com os gestores e analisados com auxílio do software Nvivo, por meio da análise de discurso. O resultado da pesquisa foi um levantamento das tarefas com resultado no curto e longo prazo em ambientes hospitalares, identificação dos dilemas do sistema de saúde que impactam na gestão e a proposição de hipóteses de variáveis que possam impactar na OTG. As hipóteses levantadas são que no setor hospitalar fatores como dilemas com operadoras de saúde, incerteza do ambiente e de tarefa e gestão de urgência podem impactar na OTG de curto prazo, enquanto sistemas estratégicos de avaliação de desempenho, motivação prósocial, desenho do contrato de LP, gestão por processo e tempo de proximidade com a atividade final podem impactar na OTG de longo prazo. / This study investigates the interference of cognitive, organizational and economic aspects in Managerial Time Orientation (MTO) of large hospitals in the state of São Paulo. The literature predicts that MTO is influenced by incentive systems , like the system of managerial remuneration, and this research was analyzed other perspectives that would impact this relationship, based on accounting, economic, psychology and hospital management literature, although others factors could impact the MTO as the manager\'s contract design ex -ante, business processes, uncertainty of the environment and task, strategic system of performance evaluation of the manager and the proximity to the core activity. The study was conducted with 18 managers in 5 hospitals and 1 health insurance, analyzing the factors that impact the execution of tasks and managerial decision-making, focusing on differentiating activities of short and long term and what are the drivers that focus on results short or long term. Data were obtained through interviews with managers and analyzed using the software NVivo, through discourse analysis. The result of the research was a survey of tasks result in short and long term in a hospital, the dilemmas of the health system that impact the management and a propose hypotheses of variables that may impact the MTO. The hypotheses are that the hospital sector factors such dilemmas with health insurance companies, environmental uncertainty, task uncertainty and emergency management would impact in the short term MTO, while strategic systems performance evaluation, social motivation, design of the contract, process management and time of proximity to the core activity would impact the long term MTO.

Currently, hospital organizations represent the most wmplex contemporary companies due to their structure, processes and ciients specificities. In order to achieve the hospital aims, its management should be concemed with business as well as health assistance, improving the scarce financia1 resources to offer qualified assistance to the population. In this area, it is increasing the difficulty to access speciaiiied services, mainly regarding poorer communities. Perhaps, it is because of the govemment lack of intemt and low investtnents in public policies and preventive health care, thereby aggravating the problems faced by these organizations management. In this health chaos, it is necessary to invest in the hospital management system, either public or private. Therefore, the objective of this research is to propose an evaluation and diagnosis methodology of hospital management based on the Productivity and Quality Gaucho Pmgram (PQGP) and the Brazilian Program of Hospital Accreditation. This study is a descriptive, qualitative and bibliographical research that made it possible to develop a comparison between the two programs critena in order to verifi convergent and divergent aspects. After this analysis it was found that both programs present compatible and complementary aiteria. Thus, the evaluation methodology proposed will benefit assessment and diagnosis of health institutions, satisfying specific criteria, including legislation, and will enable the organization to score points and to get prizes offered by the PQGP as a reward for the effort to the improvement of the sewices quality and aiming at excellence. / Atualmente, as organizações hospitalares representam as empresas mais complexas da modernidade, devido as suas especificidades de estrutura, processos e clientes. Para atender a missão do hospital, sua gestão deve estar voltada tanto ao negócio quanto para a assistência à saúde, otimizando os escassos recursos financeiros a fim de oferecer assistência com qualidade h população. A dificuldade de acesso aos serviços de saúde especializados nesta área é crescente, principalmente às comunidades mais carentes. Talvez, pelo descaso governamental que pouco investe em políticas públicas e saúde preventiva, agravando assim os problemas de gestão dessas organizações. Neste caos que a saúde enfrenta, urge investir no sistema de gestão das organizaç5es hospitalares, sejam elas públicas ou privadas. Assim, o objetivo deste trabalho foi propor uma metodologia de avaliação e diagnóstico da gestão hospitalar com base no Programa Gaúcho da Qualidade e Produtividade e no Programa Brasileiro de Acreditação Hospitalar. Este estudo caracteriza-se por ser uma pesquisa descritiva, qualitativa, biblioafica, que permitiu elaborar um alinhamento de critérios entre os dois programas com o intuito de verificar pontos convergentes e divergentes. Essa análise propiciou concluir que ambos os programas apresentam critérios compatíveis e complementares. Deste modo, a metodologia de avaliação proposta trará benefícios na avaliação e diagnóstico das organizações de saúde, satisfazendo critérios específicos, inclusive no que se refere à legislação, além de possibilitar que o órgão aferido receba pontuação e participe das modalidades de premiação oferecidas pelo PGQP, como reconhecimento do esforço para a melhoria da qualidade dos serviços em busca da excelência

La problématique est de savoir quels dispositifs du management hospitalier sont transférables. Comment ce transfert doit être mis en oeuvre ? Comment se construit la coopération et quels outils de management hospitaliers français peuvent être transférés. La première partie concerne la construction et le pilotage de la coopération entre l’hôpital N° 3 de Nanchang et le Centre Hospitalier de La Rochelle. Cette première partie comprend la coopération managériale franco/chinoise à travers l’étude de la littérature et porte sur la construction de la coopération entre les hôpitaux chinois et français. Sont étudiées ensuite les raisons de la coopération vues du côté des hôpitaux chinois et vues du côté des hôpitaux français. Ensuite est traité le pilotage de la coopération entre les hôpitaux chinois et français et le rôle des acteurs des terrains, la dimension institutionnelle, les évolutions du pilotage et les difficultés de ce pilotage. La deuxième partie traite des outils et méthodes pour lesquels un transfert peut-être envisagés. Est listé un certain nombre de pistes d’adaptation d’outils qui ont été explorés. Enfin est explicité les deux projets qui ont été retenus, l’organisation de l’activité médicale autour de pôles cliniques et le développement du contrôle de gestion. La troisième partie développe l’expérimentation sur ces deux projets. Enfin, il est traité les conditions pour réussir un partenariat entre des hôpitaux chinois et des hôpitaux français engageant les clés de la réussite d’une coopération entre hôpitaux français et chinois. / The issue is to know what package of hospital management could be adjusted to another country. How could it be apply ? How is building cooperation and what tools of French hospital management could be adjusted? The first part is about the establishment and the steering of a project between Nanchang’s hospital (N°3) and the hospital of La Rochelle. It includes managerial cooperation between France and China enlightened by scientific publications and explains how cooperation is building between French and Chinese hospitals. It also talks about the reasons why they decided to cooperate. Then, it is about how to manage cooperation between French and Chinese hospitals including the economic agents, the institutions, the development and the difficulties. The second part is about required tools and methods to prepare a transfer. It details some examples that could be reused. Finally, it explains how were selected the two projects, the organisation of medical activity and the development of management control. The third part is about testing. To conclude, it explains how succeeding a partnership between French and Chinese hospitals in order to get to a successful cooperation between both institutions.

Hospitals, like other knowledge-intensive organizations are today more dependent than ever before on intellectual capital (IC). lC consists of non-physical sources of knowledge used for value creation for key stakeholders. It comprises of human, structural and relational capital and becomes more often the key point for sustainable competitive advantage. The respective value is generally not reflected in the balance sheet. Indeed there are possibilities to disclose information on IC in supplementary or annual reports in order to reduce the lack of information on value drivers. The German hospital market is in a significant transition and trends of privatization, consolidation and a rising need for external capital become apparent. This increases the necessity for determination of a hospitals' value and key value drivers. The aim of the present thesis is to answer the questions of how IC in hospitals is measured and the how the information is disclosed to answer consequently the question if the analyzed tools can show the added value gained by IC. Finally, the analysis should find an answer on whether the reports can influence the valuation of hospitals and create a positive effect. The study is based on data gathered by five external available reports of national and international hospitals comprising information IC. The analysis includes both an examination of extent and quality of IC disclosure through the usage of content analysis and a disclosure index derived from previous studies and aligned to the special field of interest. Additionally, the reports were analyzed whether or not certain requirements set by financial analysts for valuation are met. The results show that IC disclosure in hospitals can be provided with or without making use of frameworks for IC reporting, or by including the information in annual reports. The majority of information is disclosed in a qualitative narrative way what brings the limitation, that only an indirect derivation of value drivers and the contribution to business success of the hospitals is possible. Theoretically, in all cases the information asymmetry between hospitals and the financial experts could be decreased, which would consequently lead to a more appropriate determination of the hospitals' value.

Purpose - This paper aims to introduces a measure to assess the perceived effectiveness of multi-hospital organizations (MOs). Design/methodology/approach - A sample of top managers of non-profit hospitals serves as the study setting. Data were collected via mail surveys. Usable responses were obtained from 189 hospitals. The measure was developed by considering the instrumentality and effect components of a set of relevant motives for joining an MO. During the course of the study, three alternative formulations were examined. Findings - Results show that the measures based on effect alone and a multiplicative combination of effect and instrumentality demonstrate sound psychometric properties. The recommendation here is to adopt the latter measure. Research limitations/implications - The study was limited to a particular sample. Replications among other samples are needed to validate the current findings. Also, because the exact content of the objective function of a hospital for joining an MO is not necessarily constant over time, there is a need to conduct similar studies on a periodic basis. Practical implications - The measure recommended here uses multiplicative/weighted instrumentality and effect scores as opposed to only the instrumentality or effect scores. This makes it possible to go beyond the mere "why" or "how" questions. Simultaneous consideration of instrumentality and effect dimensions affords a richer and more relevant understanding. Originality/value - Valid and reliable measures of performance are critical for both managerial and research purposes. The measure proposed in the current study could be used in structural equation models to investigate the effect of individual actions on performance and the impact of performance on other outcome measures (e.g. intentions to stay in an MO).

Ett sjukhusledningssystem (HMS) är en integrerad programvara/system eller applikation – oavsett om det är webb, desktop eller mobil – som hanterar olika arbetsflöden på ett sjukhus. Ett välbyggt HMS hanterar smidig prestanda för hela sjukvårdssystemet från administrativ till medicinsk, ekonomisk, juridisk och patienthantering. Detta är hörnstenen för en framgångsrik drift av vårdinrättningen. Ett väl avstämt arbetsflöde för sjukhusledning säkerställer att flera viktiga beslut som påverkar personal och patienter tas på ett snabbt och mest effektivt sätt. Detta kan vara mycket svårt att implementera nuförtiden utan det distinkta sjukhusledningssystemet, särskilt med tanke på det enorma antalet patienter som kräver kritisk läkarvård i förhållande till de tillgängliga faciliteterna. I det här projektet har jag för avsikt att utveckla, implementera och utforska programvara för sjukhusledning, vilka funktioner den utför och hur den kommer att hjälpa sjukvårdsindustrin i mitt land att bli mer effektiv, effektiv och patientcentrerad. Därför kommer mitt huvudfokus i detta projekt att vara att designa ett unikt sjukhusledningssystem för en privat vårdgivare som heter WeCare Hospital. Detta system kommer att förbättra sjukhusupplevelsen för patienter, läkare och sjukhusmyndigheter. Applikationen kommer att köras på internet och kommer att vara robust och snabb nog att nås med alla typer av nätverkssystem (3G eller 4G smartphone) eftersom det kommer att vara en lätt och smidig applikation. Hela systemet är utvecklat med moderna webbutvecklingsteknologier som PHP, JavaScript, HTML5 och CSS3. / A Hospital Management System (HMS) is an integrated software/system or application – be it web, desktop or mobile – that handles various workflows in a Hospital. A well-built HMS manages the smooth performance of the whole healthcare system from administrative to medical, financial, legal and patient management. This is the cornerstone for the successful operation of the healthcare facility. A well-tuned Hospital Management workflow ensures that several important decisions that affect the staffs and patients are made in a quick and most efficient manner. This can be very difficult to implement nowadays without the distinct hospital management system, especially given the huge number of patients that require critical medical attention in relation with the available facilities. In this project, I intend to develop, implement and explore hospital management software, what functions it performs and how it will help the healthcare industry in my Country to be more effective, efficient and patient-centric. Thus my main focus in this project will be to design a unique Hospital Management System for a private healthcare provider called WeCare Hospital. This system will improve hospital experience for patients, doctors and the hospital authorities. The application will run on the internet, and will be robust and fast enough to be accessed with all kinds of network systems (3G or 4G smartphone) as it will be a light and fluid application. The whole system is developed with modern web development technologies such as PHP, JavaScript, HTML5 and CSS3.

Made available in DSpace on 2016-08-10T10:29:32Z (GMT). No. of bitstreams: 1 Renato Antonio Campos Freire.pdf: 19801495 bytes, checksum: 0a96331b0fd8d4a7be741e0abfffb440 (MD5) Previous issue date: 2009-07-27 / Evaluation of antimicrobials in hospital is complex and multifaceted detail, where the monitoring can contribute greatly to therapeutic efficacy and reduction in hospital costs. The work aims to describe the profile of hospital use of antibiotics in children with restricted use, in an attempt to contribute to reducing costs, improving hospital management and monitoring of hospital infections, bringing to patient safety and therapeutic efficacy leading to better quality of life, as well as the monitoring system of audit of antibiotics, identification of pharmacotherapeutic profile and rational use of medicines in accordance with pre-established clinical protocols. It is a retrospective cross-sectional study conducted from August to October 2008 in the pediatric HMDO service. Data collection was performed through the software internal use of the hospital, with specificity in two modules of the system of hospital infection and management of hospital admission and, recognizing and monitoring the therapeutic antibiotics in children according to clinical protocols of the unit of hospitalization. All these data were taken from the internal information system of the hospital so online. Data were collected as the type of infection, infection of the topography, lists of antibiotics used, dosage, route of administration, frequency, duration of treatment. The antimicrobials used were selected according to the pharmaceutical form, dose prescribed and the corresponding volume. There was no use of antimicrobials in accordance with the pre-clinical protocols established by the institution. It is appropriate therapeutic use of antibiotics through a check list, a systematic control of fulfillment of the prescription of antibiotics, continued education of prescribers and compliance with clinical protocols. / Avaliação de antimicrobianos a nível hospitalar é um processo complexo minucioso e multifacetado, onde o monitoramento pode contribuir muito para eficácia terapêutica e diminuição de custos hospitalares. O trabalho visa descrever o perfil de utilização de antimicrobianos hospitalares de uso restrito em pediatria, na tentativa de contribuir para a diminuição de custos, melhoria da gestão hospitalar e monitoramento das infecções hospitalares, trazendo ao paciente segurança e eficácia terapêutica que levem à melhor qualidade de vida, bem como no acompanhamento do sistema de auditoria de antibióticos, identificação do perfil farmacoterapêutico e uso racional de medicamentos de acordo com protocolos clínicos pré-estabelecidos. Constitui-se de um estudo transversal retrospectivo realizado no período de agosto a outubro de 2008 no serviço de pediatria do HMDO. A coleta de dados foi realizada através do softwear de uso interno do hospital, com especificidade em dois módulos do sistema de infecção hospitalar e gerenciamento de unidade hospitalar e internação, reconhecendo e monitorando os antibióticos terapêuticos em pediatria, de acordo com protocolos clínicos da própria unidade de internação. Todos estes dados foram extraídos do sistema de informação interno do hospital de forma on line. Foram coletadas informações como o tipo de infecção, topografia da infecção, listas dos antibióticos utilizados, dose, via de administração, freqüência, duração do tratamento. Os antimicrobianos consumidos foram selecionados de acordo com a forma farmacêutica, dose prescrita e volume correspondente. Observou-se não conformidade na utilização de antimicrobianos com os protocolos clínicos pré-estabelecidos pela instituição. Propõe-se adequação na utilização dos antibióticos terapêuticos através de um check list, um controle sistemático do preenchimento da prescrição de antimicrobianos, educação continuado de prescritores e cumprimento de protocolos clínicos.

Submitted by Joana Azevedo (joanad@id.uff.br) on 2017-10-10T13:31:36Z No. of bitstreams: 1 Dissert Francisco José A Silva Mattos.pdf: 1529652 bytes, checksum: 6268c76551c3f49818b5d1bdf625aba0 (MD5) / Approved for entry into archive by Biblioteca da Escola de Engenharia (bee@ndc.uff.br) on 2017-10-10T13:44:25Z (GMT) No. of bitstreams: 1 Dissert Francisco José A Silva Mattos.pdf: 1529652 bytes, checksum: 6268c76551c3f49818b5d1bdf625aba0 (MD5) / Made available in DSpace on 2017-10-10T13:44:25Z (GMT). No. of bitstreams: 1 Dissert Francisco José A Silva Mattos.pdf: 1529652 bytes, checksum: 6268c76551c3f49818b5d1bdf625aba0 (MD5) Previous issue date: 2017-09-22 / Há um interesse crescente na gestão das Centrais de Abastecimento Farmacêutico (CAF) em hospitais públicos, como também em unidades particulares. As cadeias de suprimentos farmacêuticos e a distribuição de medicamentos internamente em uma unidade hospitalar tem uma complexidade impar, característica da existência nosocomial. Este trabalho tem por objetivo a elaboração de um modelo que auxilie as CAF presentes em unidades hospitalares a avaliarem a maturidade dos seus processos. O modelo foi elaborado com foco em instituições hospitalares públicas, por conta do maior acesso à essas instituições. Para alcançar esse objetivo realizou-se uma ampla pesquisa bibliográfica, aliada a consulta à especialistas para a elaboração do modelo de avaliação, que foi aplicado em cinco hospitais públicos e dois hospitais privados, todos localizados na cidade de Niterói. O modelo proposto mostrou-se adequado e de fácil aplicação, possibilitando avaliar e identificar pontos fortes e fracos no processo gerencial. Os profissionais especialistas entrevistados apontaram como fator positivo a aplicação do questionário, e observaram que apesar da existência de normas e procedimentos percebe-se uma dificuldade de execução destes. Os resultados mostram que os hospitais avaliados apresentam nível de gestão Gerenciado e apresentam muitos processos com oportunidades de melhoria. A aplicação do modelo favorece a identificação de processos dependentes de melhorias e apresenta situação gestora com qualidade desempenhada pelas unidades publicas em comparação ao hospitais particulares analisados / There is growing interest in the management of Pharmaceutical Supply Centers (CAF) in public hospitals, as well as in private units. Pharmaceutical supply chains and the distribution of drugs internally in a hospital unit have an odd complexity, characteristic of nosocomial existence. The objective of this work is the elaboration of an instrument that will help the CAF present in hospital units to evaluate the maturity of their processes. The instrument was developed focusing on public hospital institutions, due to the greater access to these institutions. In order to reach this goal, an extensive bibliographical research was carried out, together with the consultation of specialists for the elaboration of the evaluation instrument, which was applied in five public hospitals and two private hospitals, all located in the city of Niterói. The proposed instrument was adequate and easy to apply, making it possible to evaluate and identify strengths and weaknesses in the management process. The professionals interviewed pointed out as a positive factor the application of the questionnaire, and observed that despite the existence of norms and procedures it is perceived a difficulty of execution of these. The results show that the hospitals evaluated have a level of managed management and present many processes with opportunities for improvement. The application of the instrument favors the identification of processes dependent on improvements and presents management status with quality performed by the public units in comparison to the particular hospitals analyzed.

This case study describes the learning capability of a hospital after patient incidents. The theoretical framework is based on Carroll, Rudolph and Hatakenaka’s model of four stages of organisational learning. Ten managers were interviewed and documents such as incident management policy, quality plans and incident reports were examined. The ten participants include five clinical managers who are responsible for investigating incidents and five unit managers who are responsible for signing off incident reports. This study found that incident investigations generated valuable learning for the participants. Being the learning agent, they also appeared to influence and lead team learning and, to some extent, organisational learning. Most of the participants appeared to be practising between the constrained stage and the open stage of learning. This study uncovers the concepts of preparedness, perception and persistence. The application of these exemplary concepts has strengthened the learning capability of some participants and distinguishes them as practising at the open stage of learning. By employing these concepts, The Hospital can also gain leverage to progress from the constrained stage to the open stage of learning that supports a systems approach, advocates double-loop learning and facilitates the culture of safety. This case study has found that The Hospital assumes a controlling-orientation to ensure staff’s compliance with policies and procedures to prevent patient incidents. However, it also advocates a safety culture and attempts to promote learning from patient incidents. This impetus is inhibited by the obstacles in its incident management system, the weak iii modes of transfer of learning and hindering organisational practices. Three propositions are offered to overcome these barriers. Firstly, revolutionise the incident management system to remove obstacles due to the rigid format of Incident Forms, the difficulty in retrieving information and the lack of feedback. Secondly, provide regular, safe, transparent and egalitarian forums for all staff to learn from patient incidents. Facilitated incident meetings have been shown to be more effective platforms for learning than a bureaucratic approach via policies, procedures, training and directive decisions delivered during departmental meetings or by written communications. Thirdly, attain a balance between controlling and learning to mitigate the effects of bureaucratic process and the silo phenomenon.