The business of the Blue Angels, the Navy’s precision aerobatics team, would seem to be about as far away from the business of utility restoration and incident command center (ICS) as you could imagine. But we could still learn a lot from how they go about their business.
They have a plan, incredibly detailed and precise, that must be executed exactly the same way every time they drill and every time they perform. And they drill a lot. They follow checklists religiously to make absolutely sure that all resources are available and all systems are fully functional. And along with the thrill and spectacle of each performance, there is an overriding commitment to safety.
Perhaps the biggest lesson the Blue Angels have for anyone involved in incident command is how seriously they debrief every drill and every performance. Before the pilots, ground crew and superior officers enter the debriefing room, each one of them symbolically removes his or her rank insignia.
So how’s your debrief process? Is the feedback you get meaningful and actionable? Do you debrief every drill and every time you have a significant event? Do you document, present and work to address the findings? Do you provide feedback to those who participate in your debriefs, so they’ll know that recommendations are being made and seriously considered? Does everybody leave their rank outside the room to assure honesty and candor?
In short, what do you do to keep history from repeating itself?
“History is a race between education and catastrophe.” ~ H.G. Wells
A recent article in The Joint Commission Journal on Quality and Patient Safety provides recommendations for a thorough incident debriefing process. In their article, the authors lay out 12 evidence-based best practices and tips for a debriefing:
- Debriefs must be diagnostic.
- Ensure that the organization creates a supportive learning environment for debriefs.
- Encourage team leaders and members to be attentive of teamwork processes during performance episodes.
- Educate team leaders on the art and science of leading team debriefs.
- Ensure that team members feel comfortable during debriefs.
- Focus on a few critical performance issues during the debriefing process.
- Describe specific teamwork interactions and processes that were involved in the team’s performance.
- Support feedback with objective indicators of performance.
- Provide outcome feedback later and less frequently than process feedback.
- Provide both individual and team-oriented feedback, but know when each is most appropriate.
- Shorten the delay between task performance and feedback as much as possible.
- Record conclusions made and goals set during the debriefing to facilitate feedback during future debriefings.
“These debriefing principles come from research in aviation, the military, and crisis management organizations,” explains Eduardo Salas, PhD, Pegasus Professor of Psychology at the University of Central Florida in Orlando and lead author of the article. “We know from our findings that teams that engage in a debriefing perform better [in the future] because they learn. It is a key component, especially for teams, to evaluate what happened and what can improve, what the weaknesses were, and set goals for better performance.”
A debriefing, he says, differs significantly from a root-cause analysis. “To be useful, it has to happen right after the incident or critical event, although depending on the nature of the situation, it can be a couple of days,” says Salas. A debriefing, he adds, has to be not only timely, but also developmental.
“When a team discusses a weakness, they have to come up with a remediation task,” he says, adding that the debriefing also must be diagnostic. “Saying we have a communication problem is not sufficient; that’s’ a big bucket,” he emphasizes. “A debriefing really helps you understand what led to what.”
The biggest obstacles to effective debriefing? Lack of planning, lack of leadership, poorly defined processes, lack of resources, lack of training, event fatigue, the press of “business-as-usual” – you can take your pick of excuses. But if we learn nothing from history… well, you know what’s bound to happen.
1. Salas E, Klein C, King H, Salisbury M, et al. Debriefing Medical Teams: 12 Evidence-Based Best Practices and Tips. Jt Comm J Qual Patient Saf. September 2008, Vol. 34, No. 9: 518-527