CQI and Performance Evaluation: The Debrief

July 3rd, 2014

Continuous quality improvement is well known to us and integral to the culture of 3M. We often think of this as process improvement, employing Six Sigma and Lean methodologies. There is a distinctly human aspect to evaluation of individual and critical team performance because of opportunities for personal growth and refinements to team dynamics, respectively. Tremendous value is achieved when individuals bring absolute honesty and integrity to the process.

There are heuristic tools that are very helpful in structuring the evaluation of critical team performance. One of these is the debrief. This should be conducted with all involved team members as soon as feasible after completion of an event or project, when recent actions and outcomes are freshest. There is no place for complacency in a debrief – as a matter of safety or as a matter of optimized process. A debrief focuses on the reflective process for individuals and the group.¹ A great explanation and demonstration of a performance debrief may be found under “Blue Angels Debriefing” on YouTube. The Blue Angels conduct debriefs in a constructive and respectful fashion, with rank and experience put aside. As Eric Haney, a founding member of Delta Force, has written:

“The purpose of the review was to learn everything we possibly could about what we had just done – the good, the bad, and the ugly. We dissected problems and we came up with solutions – and the whole group profited from what we learned.

There is no better way for an organization to improve itself and move forward in a professional manner. But it is a process that must be fundamentally rooted in trust and mutual respect. The very instant it becomes a weapon rather than a lens for diagnostic analysis, the process is dead.²”

At TOPGUN, the Navy Fighter Weapons School, debriefs are composed of three questions³:

  1. What went well?
  2.  What should we do differently to improve our performance?
  3. How, specifically, will we make that happen?

The first part–reviewing what went well–serves to recognize both individuals and performance in fostering habitual and cultural growth. The second question critically evaluates personal and team performance, while the third begins to create an incremental roadmap to improvement with the next iteration. The debrief begins with observations of the most junior person in the room (perhaps the freshest perspective), and includes all participants. As Steve Harden, Chairman and CEO of LifeWings and former TOPGUN Instructor has said, “The nut of every event is always the thought process. Why did you do what you did?”4 The nut is also referred to as the frame by other authors and is a construct of: assumptions, feelings, emotional states, goals, knowledge base, situation(al) awareness, and context – expectations and equipment.5,6 In the latter regard, the debrief serves not only as a vehicle for the system to learn and evolve, also to defuse conflicts arising from differences in expectations. The concept of frame is also inclusive of an individual’s accountability for both preparation and performance.

Lest you think that only the military can benefit from such structure, a well known guide for meetings from the patient satisfaction team of the Heart Center at Cleveland Clinic Foundation is referred to as Rimmerman’s Rules:

  • Leave rank at the door (i.e., all team members are created equal)
  • No whining
  • At least one bright idea per session
  • No sidebar communications
  • If you have something to say, say it in the room
  • No hostages; leave if you don’t want to be here
  • Identify problems but focus on solutions
  • Review the next objectives before leaving – ensure they are realistic in scope
  • Leave with a sense of accomplishment
  • Expect work outside of the meeting – use subgroups and task forces

Each meeting is rated by participants on a 1-10 scale. Any person ranking the meeting an eight or below gives suggestions for improvement. Each participant ranks his or her own participation as well, in the same manner.

The techniques presented serve as examples. There are clearly many ways to achieve the same end – the professional, respectful, constructive, and tireless pursuit of excellence.

“Glad to be here!”

Matthew M. Cooper, MD, MBA, FACS is Medical Information Director for 3M Health Information Systems.

¹Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthcare;2(2):115-125.

²Haney EL. Inside Delta Force. Bantam Dell, New York. 2002; 109.

³Harden S. Three Questions TOPGUN Pilots Ask Every Day. LifeWings Partners, LLC. www.SaferPatients.com.

4Harden S. Personal Communication.

5Rudolph JW et al. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthcare; 1:49-55.

6Rudolph JW et al. Which reality matters? Questions on the path to high engagement in healthcare simulation. Simul Healthcare; 2(3):161-163.