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E23: Safety-II inspired debriefs (Quickisode) · Safe As Podcast

• 0:07
  Welcome to Quick Aside 2 on Safe as a frantic and brief
• 0:11
  exploration of a tool or concept.
• 0:14
  Today we're focusing on a debriefing tool drawing on
• 0:17
  Safety 2 insights. This is from the paper from
• 0:21
  Bentley 2021 titled Debrief it All, a Tool for Inclusion of
• 0:27
  Safety 2 published in Advances in Simulation.
• 0:31
  Debriefs often, but not always, focus on what went wrong.
• 0:35
  A safety tool approach then focuses on what went wrong but
• 0:39
  also emphasises what went right. So safety tool is not just about
• 0:44
  minimising unwanted factors but maximising desired factors.
• 0:49
  Deming said the same thing, but whatever.
• 0:51
  The authors piloted a tool to guide debriefs.
• 0:55
  It has four key phases, setting the scene, description of the
• 0:59
  case, analysis of insights and take home points.
• 1:04
  Let's jump straight into the meat and veg, so one setting the
• 1:08
  scene. The safety tool concept
• 1:10
  highlighted here is safety tool shifts more focus to the
• 1:13
  complexity and adaptability of the system and capitalise on
• 1:17
  good performance. Safety is not about the absence
• 1:20
  of negatives, it's really also about the presence of
• 1:23
  capacities. So the debrief tool uses some
• 1:26
  sample language or phrases to tease out these elements.
• 1:30
  For instance, let's take a look at how our work really operates,
• 1:34
  including the systems and relationships that support us.
• 1:38
  We'll also discuss the challenges we may encounter and
• 1:40
  how we adapt or overcome those challenges.
• 1:44
  How we adapt in different circumstances offers insights
• 1:46
  into why we succeed. Let's unpack them.
• 1:50
  And understanding how things work and why they go right helps
• 1:53
  us improve. So let's talk about that 2
• 1:56
  description of the case or event.
• 1:58
  So this is where they actually go through what they're going to
• 2:01
  focus on today in the D roof for the safety two element, there's
• 2:05
  a value of understanding normal workflows, work is done versus
• 2:08
  just purely the work is imagined or work is prescribed that
• 2:12
  you'll find in SOP's and procedures or even in their
• 2:15
  managers mental models. Key phrases here could be, can
• 2:19
  you please share their facts or a short summary of the case that
• 2:22
  we're covering. 3 for analysis for the safety 2 elements here.
• 2:28
  How does the work actually work? We have a variability,
• 2:32
  adaptability, workarounds, near misses, and hard mitigation
• 2:36
  strategies. In other words, what conditions
• 2:39
  make success more likely or more difficult?
• 2:42
  Sorry, some of the questions at this part of the debrief.
• 2:45
  Let's focus on what went well. Why did X go so well in this
• 2:48
  case? How can we ensure this happens
• 2:51
  again this way in the future? How did people adapt to overcome
• 2:55
  challenges in this case? What behaviours facilitated good
• 2:58
  performance? What resources enabled good
• 3:01
  performance? What were our underlying
• 3:03
  assumptions and were they accurate?
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  How does this work usually happen?
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  Are the behaviours or resources reliably available?
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  Are there strategies that we use in this case, or that you use in
• 3:14
  your normal work to be more efficient or more effective?
• 3:18
  How has this played out during a similar clinical situation?
• 3:21
  Other examples of cases like today's when it didn't go well,
• 3:25
  What is the difference between that case and today?
• 3:28
  How do we ensure reliability of available resources and
• 3:31
  encourage useful behaviours? Then at the end reversing some
• 3:35
  of these questions to explore what could be done differently
• 3:38
  or could be improved in the future.
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  So types of counterfactuals in prospective situations and
• 3:43
  thinking 4 the take home points for the safety tool elements.
• 3:48
  This is about reproducing success and identifying
• 3:51
  opportunities for systems improvement for the phrases for
• 3:54
  the debrief. What occurred in this case that
• 3:57
  we want to continue in the future?
• 4:00
  What is needed to ensure this happens reliably again in the
• 4:02
  future? How can each of us help to make
• 4:05
  this happen? This paper is Open Access, so
• 4:08
  check it out if it interests you.
• 4:10
  That's it on this quicker side of safe as.
• 4:12
  Thanks everybody.