Guidance

Toolkit 8: UHKSA constructive debriefing and lessons identified

Published 21 January 2025

The lessons identified process in UKHSA is based on an end-to-end pathway approach to capture learning from each incident or exercise, ensure that lessons identified are acted upon, and improvements in practice are implemented. Exercising can support implementation of lessons identified.

It is important that any lessons identified process enables the views of all those involved to be gathered at the individual and group level while keeping the process simple but inclusive. The scope of the debrief must be made clear to all participants and high-level objectives should be agreed to ensure areas of good practice are captured, issues, challenges and their root causes are identified, and clear recommendations for actions are agreed. Participants must be given every opportunity to communicate their observations freely and honestly in a safe environment that fosters a culture of learning and transparency.

Core principles for lessons identified in UKHSA:

• information is collected for the purposes of continuous improvement, organisational learning, and supporting staff needs as identified, and should be treated with anonymity wherever possible for impartiality and objectivity
• a ‘no blame’ culture is fostered and lessons identified should be a normalised process within regular discussions. This means the focus of learning lessons should not be on blaming individuals, but on reviewing all available facts and perspectives that will help improve processes and outcomes
• continuous improvement is a constant cycle, requiring regular review and monitoring to ensure lessons and practices become embedded and processes become refined or enhanced
• both areas for improvement and areas of exemplary practice should be integrated into an open culture of sharing across directorates

By default, any person leading a outbreak response is responsible for ensuring learning is captured at the end of the outbreak. If the outbreak is likely to be protracted, it is good practice to ensure that ‘in action reviews’ take place to ensure good practice is being maintained and to identify, and respond to, lessons throughout the outbreak management process.

Approaches to identifying lessons

Debriefing aims to identify issues that need to be addressed, and to identify and assign lessons to improve future response.

There are different ways to facilitate the discussions within the debrief meeting to enable the identification of lessons. An IMT may choose to undertake debrief in a range of ways:

• hot debrief: immediately after the incident or period of duty, for example within 48 hours
• structured/organisational/cell debrief - within two weeks post incident
• multi-agency debrief - within four weeks of the close of the incident
• post Incident Reports - within six weeks of the close of the incident

Debriefs can be held face to face or virtually as required. Minutes are not normally taken for debrief meetings; however, outputs would be recorded within the debrief report.

Certain themes that may be considered as part of debrief processes include:

• outbreak preparation and planning, at internal and inter-organisational levels
• outbreak control decision making and the impact of decisions made
• coordination of incident response activities, including internal and inter-organisational coordination and governance
• resource availability to support effective outbreak management
• communications and engagement with relevant partners throughout the outbreak management process

Within each theme, the impact on health inequalities and what mitigations should be put in place for future incidents should be considered. Following any debrief, lessons identified should be included in outbreak reports, where appropriate, and disseminated to partner agencies and key stakeholders. Agencies and appropriate forums should ideally review learning against local plans within 12 months of the formal closure of the outbreak.