The US Forest Service (USFS) operates in a highly dynamic and high-risk environment. Changes can happen which can have catastrophic circumstances if they are not picked up. Unfortunately, sometimes things do go wrong and firefighters die or large amounts of property is lost. However, the USFS recognises that failure is a learning opportunity irrespective of what the outcome was. They also believe that exactly the same circumstances are unlikely to appear again so fixing that exact same problem will have limited impact on operations. However, there are probably other gaps in their safety protocols that need to be identified and fixed and that is the purpose of a Learning Review.
Given that we have so many ‘similar’ accidents, I believe that the same 'learning from failure' mindset should be developed within the healthcare community - that was the motivation for this article.
The US Forest Service (USFS) published a document in 2014* outlining how they undertake learning reviews. This followed a massive failure of a Serious Accident Inquiry (SAI) where learning was limited.
"That process was a total failure and set a new low bar for learning opportunities following serious accidents. The USFS prohibited their employees that had specific knowledge about the fire from being interviewed."
A revision of their 2014 Learning Review process is due shortly but I thought it an ideal point to identify how this organisation deals with risk in a very dynamic environment, how they learn from failure AND successes, and see what healthcare professionals can learn from them.
"Accident prevention is the key objective of any incident study” according to the USFS. Furthermore, to help improve honesty and frankness, the Chief of the USFS has openly stated that "information derived from any Learning Review will only be used by the agency for accident prevention purposes. This means that the Learning Review (as delivered under a formal USFS protocol) will not be used as the basis for disciplinary action, or to place blame on employees."
“Products and information that were the result of the Learning Review will not be used for administrative, disciplinary or legal purposes by the USFS.”
This last point is a key statement when it comes to learning and is entrenched in many nation’s legislature when it comes to aviation safety. However, too often in UK healthcare, the fear of litigation or social castigation means that learning is limited to a few individuals, who often are not allowed to share the context or real story about what happened. This limits the opportunity to prevent similar events from occurring in disparate locations or communities.
The learning review follows a number of discrete steps with the aim to understand:
However, before we examine the review in more detail, it is worth understanding the entering arguments or principles on which a USFS learning review is undertaken. These are:
If we now consider each of these principles and see where UK healthcare, as a whole, lies.
The process the USFS use follows a couple of simple concepts.
The following is a summary of the USFS and work by Todd Conklin who has developed a concept called ‘Learning Teams’ to do the same in non-firefighting scenarios.
Start to understand the context in which the event took place. Because events don’t take place in isolation, there are always external pressures, drivers, biases, previous experiences etc which inform future decisions/behaviours. The learning mode is not about root cause or blaming people, things or systems, it is about telling stories. Dave Woods, a world-expert in this area, sums it up nicely. “Don’t look at the choices which workers have to make differently, look at the conditions which create operational conflict.” (Conklin, Pre-Accident Investigations (2014)).
There is a need to recognise that there is no ground truth when it comes to those involved. Everyone will have a different perspective and everyone's view is valid. Once the story has been told with all of the relevant information from those involved, we have a better idea of why it made sense for everyone to do what they did. This story-telling needs to consider the timeline of events, the mindset of those involved and the context in which they were operating. Drawing a simple timeline can help identify when decision points are made for ‘normal’ work, identifying the pressures and context in ‘normal’ work can identify gaps where safety measures are being missed, and identifying pervious experiences (positive and negative) in similar circumstances can mean that cognitive failures or biases are identified. All of this leads to a context rich story which.
An additional point which Todd Conklin highlights is the need to have a break between ‘Learning’ and ‘Fixing’. This break has two benefits. One it allows people to use the part of their brain which is creative. This is normally activated during quiet periods, especially during sleep. Indeed there is research which highlights that many ideas come to people whilst standing in the shower because their brain is doing something else. The other is that it forces a natural break between learning and fixing, thereby keeping people away from coming up with solutions to the problems bing discussed.
The fixing needs to start with a recap of what happened, in effect fixing the story to a recognised ‘common’ truth. It doesn’t mean it will be totally true, but it is essential that everyone understand the baseline from which the adverse event occurred. Then identify if anyone is missing from the discussion when it comes to coming up with solutions. For most healthcare events, it will be those directly involved and maybe the immediate supervisors. At this point, there is need to define what the ‘should have done’ is. Not because we can say ‘they broke the rules’ but because we can see where the gaps between ‘normal’ and ‘actually done’ is. It often highlights areas where normalisation of deviation has occurred. The best suggestions for ‘fixes’ come from the sharp end, they are the people who are doing the work, managing the risk as best they can, given the pressures/drivers in place. They are the ones managing the ’shortcuts’ and understand what is ‘forcing’ them to take the shortcut. Fix the reason for the shortcut, not the behaviour, it will have much longer lasting effects. Finally, it isn’t just about fixing broken stuff, often learning reviews identify opportunities for improvement in areas where failure has yet to happen.
Once the fixes have been decided, communicate them to the organisation.
Ok, so we have learned about how the USFS goes about making their dangerous job as safe as possible, how do we apply this to healthcare?
For the majority of healthcare incidents where nothing seriously goes wrong, a structured learning review is overkill but the concepts behind it are valid.
For those involved at the management level, a learning review will help identify gaps and using the experience of the team, identify ways of making things better. If the focus is on shifting the blame or limiting liability, then learning will be extremely limited. If there is a recognition that failure is normal, that there is a want and a need to get better, learning reviews are an excellent tool.
Following some training I delivered in Human Factors and briefing/debriefing techniques, one surgical team debriefs their operations and they have noticed that team members often jump to the solution space before having a complete understanding of the context, mindset and events.
Below are the references for the USFS Learning Review and Todd's excellent book.
Thanks to Timothy Van Goethem for the discussion which prompted this blog.
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