Learning from Debriefs

[Carl]

Heres a topic that I hope will get some good quality responses. 

In your FRS, how do you feedback learning from incidents back into your service so that you continually learn from them. We have quite a good system in place that may not be used to its full potential but it does appear to get great responses when other services see it. 

Does your system work? How does it work? and how do you close the final loop?

For those who have not experienced a visit from the HMICFRS, you may well get asked this question and need to provide more than a one line answer.

[Crog]

We now have an Ops Assurance Team that deal with this.

Not sure how we feedback as such, believe jo’s Can input details into a feedback form and it gets taken from there.

We also have set criteria that results in a debrief occurring for an incident. Invites are sent to all initial jo’s, level 2’s, etc to attend. It’s not compulsory, so not everyone goes. I’ve been able to attend one for a body recovery last year. Was very interesting, as we get info on the whole job and not our aspect of it. Goes from the call to control (who can also attend) to conclusion. Includes bits on equipment used, what could have been used, what we would have liked but don’t have, any h+s issues. Goes in depth and debrief lasts good few hours.

Anything that is brought then gets looked at for future incidents, r+d for equipment, etc and possibly implemented down the line. Once it’s all complete, a write up of the debrief is compiled and put on iOS assurance page on the intranet for the whole service to view. At my station, we print them all out and place in a folder for crews to go through in short learning sessions (no watches now, so easy for individuals to miss bits).

[Becile]

@Carl I remember that conversation with HMICFRS well!! Closing the loop was one of their favourite phrases I seem to remember.

We have a service improvement plan after every review, with actions assigned to departments if required. Like most were quite good at finding or commenting on what didn't go so well, but tend to not praise quite as much! It's the bigger issues that sometimes tend to rumble on or get better for a while but creep back in. For me safety behaviours and poorly filled out operational documentation was a re-occuring theme and bug bear.So much so I personally had to redesign some of our paperwork (co designed with helpful end users) All really important that may save someone's bacon either on the fireground or in an investigation or worse still legally. 

[Carl]

I am surprised I didn't get more replies on this to be honest Ian which is quite worrying considering the HMICFRS as you quite rightly say are keen on this. I guess many FRS will be highlighted if they do not have these processes in place. Its been an issue for many years and points back to the likes of the Pollock report. ☹️

[Messyshaw]

The LFB formalised their op debriefs 20 years ago. The PRC performance review of command (I think!) was in theory a great tool

After larger incidents, all incident managers would discuss their decision making rationale in chronological order. Chaired by an officer from an operational review team, it was a relaxed no blame environment aimed a learning

My first one was surprising. I went first with my account. I naively fessed up to some cock ups and was completely open. I was the only one to be so honest

The other more senior officers who presented at the meeting were simply reading from the op notes and procedures. They were not at the job I was at. Their aim was to show how bloody brilliant they were

I lost it at a subsequent PRC and exclaimed with exasperation to the chair, " I do not know what incident DO Carr was at, but it wasn't my one". Er,  that didn't go down too well!!

I hope LFB debrief sessions have changed as they are vital, as is complete openness if improvements aimed at avoiding injuries and FF deaths are to be made

There should be a big box at these meetings with a sign ' leave your egos here and collect them on the way out' 🙄

[Becile]

The bit they are really keen on is so what did you do with the learning? Did anything change?/Improve...otherwise it's just work for works sake.

I.e closing to the loop

[Matt]

Interesting this topic pops up and on Twitter today one of our GM's has tweeted that they have had their inaugural meeting of the organisational learning board, group aims to review and deliver learning from incidents at all levels.

Why does it take an inspection to realise these things need to happen?  I've been involved in god knows who many exercises and the same lessons get take away each time and never seem to get implemented at station level.

[Hmckay91]

Quote

In your FRS, how do you feedback learning from incidents back into your service so that you continually learn from them. We have quite a good system in place that may not be used to its full potential but it does appear to get great responses when other services see it.

As a small suburban/rural Paid On Call (more or less retained) fire service we have an operational debrief of any incident that warrants it (good, bad, near miss, etc.) and essentially anyone can call for one if inclined.  We are fortunate that our Command/Management Staff are operational and so participate in the debriefs as well.  Thus it is easy to incorporate the lessons learned personally as well as systemically.

Quote

Does your system work? How does it work? and hoe do you close the final loop.

 It seems to work.  Much Like Messy said; after the incident the responding members get together.  The IC outlines the chronology and critical decision making rationale of the incident.  This often helps to fill in the other officers and firefighters on the what and why.  Good points are raised and issues/concerns are identified while trying to approach it from positive learning perspective vice a bitching and blaming focus.  Clarity is often brought to the concerns but if its an operational issue or procedural issue the Command staff can get to work updating the systemic processes right away.    

[Becile]

@hmckay91 .. that type of Hot debrief is pretty common in most brigades, and is really helpful, It's the larger debriefs that often fail to address the wider service issues, which ripple through multiple departments.

[BaldyGreg]

Hi Carl

Again sorry for the late response, as Croq said, we base all our debriefs on the NOL good practice guide, we look at all aspects of the incident from start through to finish, we then collate a detailed report that is published for the entire organisation, we here in OA really look at whether training is being conducted in the way intended or policy is being adopted as intended. The outcomes of the debrief are then fed back into the organisation through the appropriate forum (Policy meetings or Equipment forums and L&D meetings) with department heads, these generate an action within our action tracker, again visible to the entire organisation, which generates a workflow with deadlines. This way some one who attends a debrief (such as Croqs body recovery) will see an action generated and has the ability to follow it through to conclusion.

Our debrief model follows a tiered approach, for instance any fire fatality triggers a tier one critical incident which then attracts a debrief.

Crews on station also have the ability to make recommendations as well, so where they believe a policy or bit of equipment doesn't meet the intend use, they fill out an OA form which again feeds back onto the tracker, so really the feedback form is the one stop shop for all, and is completely visible.

As a department we are relatively young, established in Jan 18, and we wanted to tackle and in bed debriefs fully prior to moving onto other areas of the NOL good practice guide, as such this has been our focus for the past year.

Quick question if you don't mind Carl, don't mean to highjack the question,  I've already spoken to Peter, but can I ask what other organisations do in relation operational assurance on the fire ground ?

[BaldyGreg]

2 hours ago, BaldyGreg said:

so really the feedback form is the one stop shop for all, and is completely visible

sorry, this should be the action tracker, not feedback form!!!

The action tracker is a one stop shop, central point for collating all information and distributing it to the organisation

[Carl]

7 hours ago, BaldyGreg said:

Quick question if you don't mind Carl, don't mean to highjack the question,  I've already spoken to Peter, but can I ask what other organisations do in relation operational assurance on the fire ground

Might be worth a new thread as each service should have their own Ops Assurance also

[BaldyGreg]

Thanks mate, on it now

[Carl]

Moving on with this thread and having all gone through the HMICFRS process. Has your service improved and if so how. 

I guess my original post should probably be repeated, but in short, how are debriefs undertaken, recorded and actioned. 

Has anything changed?

Interestingly, I found this document from London Fire Brigade whilst undergoing a bit of research.

[Dyson]

Yep, anything up to a 4 is debriefed by the OIC at the job normally. Anything more than a 4 goes to a PRC. Chaired by an independent DAC. All OICs and all monitoring officers will attend as well as the ORT ( fire brigade police) feels a bit like a court hearing tbh. 
 

it’s a lot of fun 🤩❤️

[BaldyGreg]

Hi 

We have a tiered approach to our incidents that is based on the outcome for our customer, this way our debriefs aren't restricted to the amount of resources assigned to the incident, we have found that by having this approach we get the same amount of learning from an incident attended by 1 or 14 pumps. All crews have the ability to raise feedback via a feedback form if they want anything raised from an incident that doesn't tick the debrief box.

We haven't changed anything following our inspection as we feel we have a solid debrief process.

[Noddy]

As an FI I make a Point of going to debriefs as I think crews like to have closure on the serious fires they go to.  Hopefully I can give them that when I go through what the cause and circumstances were.   

[John]

Hi

We have a database that anyone can access following an incident or training where you can highlight a training, procedural, operational issue, equipment issue etc and also make a recommendation, this then gets sent to a SME or relevant dept to comment on or make recommendation. Its a really good process its also used for debrief capture and Ops assurance. If they get several imputs for the same things it raises the profile of that issue. We have had some good outcomes from this system

Hope that helps a bit 

Jon