Thu, 29 Jul 2010|
This free training program from the Firefighters Support Foundation presents a disarmingly simple continuous-improvement method that is widely used in the business world but so far hasn't been much adopted by the public sector.
Automatically Generated Transcript (may not be 100% accurate)
The subject of this program. -- after action -- valuations. Now after action -- valuations go by different names the sometimes called critiques of some kind it's called to briefings and our other names as well. Now in the public safety professions the word debriefing. Has come to mean. Something like a critical stress instant debriefing where everybody gets together after something bad has happened. We don't mean the word debriefing in that specialize way in this program to the extent we use it. We mean to use the word debriefing in the sense that it has in the broader world. In which after something has happened everybody gets together to talk about what happened just happens on the bad it just you've done something significant you come together. You talk about what has happened so that you can improve how you do that same action later on or in the future. So what we're really talking about here is doing -- after -- valuation and after actually debriefing an after action report critique what if you wanna call it. After something significant we've -- and significant thing that we -- our team have done so that we can improve what we do in the future. So that we the next time we go -- that same kind of -- next time we have to do that same kind of action. That we get better. So we do these after actually valuations. So that we can continuously and -- and continuous improvement is what every high performance organization strives to do. Now looking at. The way we have done something and looking at ways we can constantly improved and the future that's just part and parcel. Of management's job -- any kind of organization that hopes to have a long life so it's part of public safety as well. -- one of the issues that gets raised when we have evaluate our performance. In a candid setting. Are the legal issues you know some people some administrators some. Some -- people are afraid to do it because they're afraid -- gonna raise -- legal liability. And -- that may or may not be true but that's really not our concern that's for the lawyers to handle that's the lawyers -- -- administration to work out together. The fact is we need to figure out a way as public safety professionals to get better and better what we do otherwise we -- -- professionals. Otherwise quote going to be stuck doing things -- when we've always -- And sooner or later that's not going to be good enough. Part of any organization and high performance organization the organization it's really trying to serve the public is were always trying to get better and better. You know if you look at the policies. Of any police department and fire department many of them will say that after any kind of significant event. You -- any kind of house for maybe so fire. In the fire service or media narcotics raid and -- service on after any kind of significant event which is supposed to do. And after action -- To sit down and figure out what went right what went wrong which can do better in the future. The fact is as prevalent as that statement is this -- and -- that policy is in many places. It doesn't get done a whole lot it gets done a whole lot less than our own policies. Suggest we should. We suggest that as a minimum you do an after action critique. After any kind of significant event in your latency and you get to define what significant -- It doesn't have to be every traffic -- -- for police officer but -- might be every narcotics trade. It doesn't have to be every time to respond to requests for public service in the fire service but it could be after any kind of -- It's up to you to decide but after any kind of significant event which suggest sit down figure out how you could do better in the future how. Future people in your profession could do better -- your agency could do -- better. You might if you're shift supervisor you might wanna have your team come together at the end of the tour and talk about what happened on that -- -- And see which could write what you can do so well how you can improve in the future. And you're an individual officer or firefighter. After every individual thing you do you might -- critique yourself. You know if you're a police officer and -- -- dozens of traffic stops every day -- -- -- and traffic. You might want -- after -- -- six traffic stop sit down just in your head ask yourself. What they do that wasn't quite technically correct in what they do that was good. Which we want to make an effort to do in the future on these next half a dozen traffic stops. And so early in the fire service for search and rescue work emergency management what -- your role is in public safety. And that brings up a point about the audience for this program the audience for this program as anybody involved in public -- Any of those four function we just mentioned police fire emergency management search and rescue -- -- Even could be anybody involved in public safety. We'll be giving examples throughout this program. It's kind of hard to find examples. Fits all of those different jobs so the examples we give me focus in on one. I'm one of those jobs rather than all of them but the point is that this program the principles we talk about -- the techniques. -- -- -- -- -- Across public safety. Now the -- cool to do after action and valuations -- cool to do continuous improvement. Has existed for decades in the business -- it's called root cause analysis. And it's just part and parcel of any well run company these days. In the eighties we had to learn from the Japanese but now industry all across the world America to China to -- Like Japan the United -- everybody uses root cause analysis as one of the fundamental tools for continuous improvement and it's a great tool to use. For after action to briefings after action critiques. Probably the best known set of these tools is called -- Toyota production system and that's the way the Toyota has utilized. A number of different kinds of quality tools. To make. Really good cars now it doesn't just apply to manufacturing -- and Utica enterprise of any kind including public safety. But it's well known it's been around for a long time. The tools that comprise the Toyota production system towards the comprised who are -- now this which one of the elements the Toyota production system. Are no secret there widely written about this lots of books about them out there if you're interested it's it's really easy to bone up on these things. Now one of the really neat things about these tools including -- -- analysis is -- it's extremely simple. It's very insightful. And it's it's worked wonders in industry. But it's extremely simple. The kinda go hand in hand anything that really cuts to the core and hopes -- make fundamental. Big change has to be fairly simple and root cause analysis is one most was its really simple but also really powerful. Now these tools have been used as we said for decades in the business world books have been written about them. And -- books have been written about them and their widely known but -- for a long time why doesn't everybody do acquire companies better than others. Well it it's even stronger than that. Can we can even make the -- -- point you might ask well why this Toyota give tours of its manufacturing plants. Two to people all across and -- what is Toyota collaborate with people who write books about their management methods if they're if they're so good when they wanna keep on secret. But the fact is they don't have to. Because knowing how to do something and actually having the discipline to do it are two different things. Knowing how to do -- the can be very very simple for instance if you want to lose weight. It's very very simple he just exercise more eat better. And but he knows that. It's no secret but having the discipline to do that every single day -- what the hard part -- same thing with these tools including -- cost analysis wouldn't be talking about this program. Knowing how to do it it's easy having the discipline to sit down and do it. After every significant a banner -- tour or or whatever you decide is the hard part. Disciplines the hard part knowing how to do something is relatively easy. -- root cause analysis. Is just what it sounds like it's looking for the -- cost the fundamental cost the foundational cause why something isn't being done as well as a could be. Whether that something is producing widgets on a manufacturing line. Or performing well as a team on our -- performing well as a company at a fire. Whatever it is -- -- your job is who cost analysis tries to figure out if something wasn't done or number of things went down. As well as it could be what's the real cost -- that doesn't try to look at the symptoms. Doesn't try to look at superficial costs. Now there are several different methods for doing root cause analysis. Different teachers have developed different methods -- by different names. But the principles of the same. If you read up on mr. disinterested and you decide you want -- with the way other people do it. Then we we show you here that's great pitchman to stick to principles were gonna show you here is a way that we think is particularly applicable to public safety. -- the way root cause analysis works. Is you. Consider the thing that didn't go quite as what was would -- with the you'd like to improve in future. And you start asking yourself what the reasons might be stuck positive reasons why. It happen. And you may get 45 different initial. Reasons why someone thinks it it didn't work out articles for -- -- -- for each one of those let's say five reasons. For each one of those start asking why so for reason actually ask well why did -- happen. And and you get why and for Weis who wondered why happen and you get -- you should keep asking why why why. Five or seven times. It's typically what people suggested you ask why 57 times and by the time you've done that. You've either got into the root cause the real reason -- and he didn't happen work out as well we hope we've gotten to a point where you can't change anything anyway. Is kind of like a little kid -- parent keeps us from Ohio -- why why why what I so we're doing here when we're -- -- a professional setting. Now as you're trying to figure out what might be the causes for whatever issue you're trying to solve it helps to have some real structure. And we suggest you use this content structure and some kind of structure that you root cause analysis industry. What you do is you put the problem trying to saw over the issue you'd like to improve at the very top. In this case will assume that it's a police raid there to arrest rate they're going into -- -- rest. And the problem was they couldn't get through the door quickly enough compete in the structure quickly enough. We suggest that she would then take that. Issue drop this kind of lines underneath it and delineate. Five separate areas that might be the problem or -- the problem might line. And those five areas are training tactics tools people and other. And you start asking yourself well what related to people might have been an issue here what -- it -- -- even -- -- etc. -- but we suggest you always start what these five pockets. In -- manufacturing environment they start usually with four standard buckets and that's people process equipment. And materials. But since we're in public safety went on manufacturing. -- -- these buckets make more sense. So to recap we suggest you put the issue which -- trying to solve or improve the top. Underneath -- Make five categories. In and start asking yourself what related to these -- categories. Might have been contributing factor. To the issue you're trying to self. So you can see what we've done here. Under each of these five categories we've listed a potential reason. Why we couldn't get to the door fast enough. We could think of anything any other category. But under people well maybe joke was the -- on the -- wasn't strong enough -- the -- Under tools -- -- maybe the ram was in effect. Wonder tactics somebody pointed out that we kept hitting the door you know we knew the -- was being effective so that wasn't real smart. And under training but we can bring all -- -- -- training we can bring all the tools -- -- to the -- that we -- used. So now gonna do is for each one of these reasons when ask well why did that happen. I wanna keep going down this change until we get to what we think is the -- -- Now obviously this is a police example. We try to think of an example that applied. Everywhere in public safety. And we just couldn't come up with one that makes sense for every branch of public safety so if -- -- one of the other branches are gonna law enforcement are the principles and the methodologies the same. On don't get hung up on the exact words were using here in specific example it's the principles -- -- So we re going back toward -- now we've got the first level. A potential. Problems suite for each one of these we asked -- why did that happen. Going back to people which is somebody suggested Joe wasn't strong -- Well comes down here we go we'll -- our strongest -- he's a pretty big guy and he gets to most stores so that's clearly not the problem. So on this branch here. This is. A dead end we stop there can quantify the -- I think about that -- strongest guy he's he's -- strong that's not the root cause. -- -- -- Someone has suggested that program was ineffective. Well. The reason Iran was in effect in effect why did that happen -- was -- ran an effective. We do know the door with barricade that's he answered that question. Coming -- the tactics issue somebody suggested we kept hitting the door you know wasn't particularly effective -- we keep doing that why we keep hitting the door. It's because we can bring any better course with us. On the trading side. We didn't bring all of artwork with -- us to the entrance site to -- site. -- we do that well we didn't do that because we've never trained to -- our full complement of course with us. And we never practiced transitioning between all the different pairs of tools that were available to us. Are much you know or something here under tactics we started talking about -- and that's okay this -- -- doesn't need to be under the course column. Because this answer revolving around tools is the right answer to this tactics question and that's okay these five -- are just starting points. The ants beat the the change that they create. The chains of question and answer why why why are gonna -- wherever they flow. So you wind up talking about tactics over -- of tactics and people it doesn't matter what you keep asking why at every level you're doing the right job. So you probably know we have to do next for each one of the second level -- we have to ask why again now remember over here and people. We've figured out this was a dead end Joe as the strongest -- -- we could do about it. So we don't have to going -- -- down there. We left off in tools are saying we didn't on the doors barricaded which is why -- -- was an effective well why didn't know the mayor white and we know doors barricaded. Well it's because we cannot crack house that's why so that's -- asked that question. Over and tactics we didn't -- better tools. We have been Albrecht was with us now why is that why do we do that it's not -- -- okay. Here we've actually reached another kind event this isn't a dead end this is something. We can do something about we can change -- recipe. So we've reached an action point here we've reached the root cause on the tactics aren't. -- -- caller we can do something about it. On the trading side we can bring all over towards what we do that well we never trained to do that again we've reached. And action Geithner that's gonna cost we never trained to do it we can do something about it that's that's actually content that addresses the root cause on the train -- But we're still stuck -- -- hear what the tools the tools column. We can take this farther and farther down to we've reached the root cause as it relates to and that's would do next. So we're gonna keep asking why -- either reach dead end or reach what we believed to be the root cause and it's something we can do something about. In this case why didn't we know was a crack house rose because we had insufficient -- -- Ask why again why we have insufficient Intel we can check with narcotics before here. Interpret narcotics bureau to see if this. They sure don't arrest this guy was a crack house or not if they had -- in California that might be useful it turns out they would have they -- -- -- North American -- So. At this point. We've reached the end here. We've reached. A root cause -- be something we can do something about which is to change RS OP before we -- generate. To check -- anyone that might know something anyone in erroneously that might know something about that place it would be really useful to us. All right so we've arrived at the point that we want -- to which was which is we have identified the root cause of why we couldn't get through historically enough. And we found three of them and they -- in the categories of training tactics and tools. We -- -- with narcotics at a time. We -- -- all of our tools with us and we hadn't trained. We all -- tools. Now the question is -- to write it identified. What the real cause was not being able to get to the door is now what you do but. Now you've got these three causes in this case because is identified. In what order -- you take on what part or if you put them in order to make some change and it's continuous improvement in your organization. We're gonna suggest three -- that you might decide in what order to attack the root causes you've identified. The first one is the easiest and that is just. Take the low hanging fruit. Like that funny stuff that doesn't really cost anything in terms of money or manpower time or resources things like changing US okay. -- -- can usually be done very easily without any resource turn. So the low hanging -- the stuff that's that's easy to do. That's cheap to do in terms of the resources -- consumes that's almost no brainer take those right away. The next tool you can use to figure out which problem to attack first. As a tool called constraint analysis. And we want to explain this to you first conceptually. Before we go into a specific example. And conceptually it's best illustrated by taking -- manufacturing line. Let's see these are the stages. Of the manufacturing like -- one stage to stage three states forced a five. These numbers here 12515115100. They represent the capacity. -- each one of those stages of the manufacturing. So let's say we start our way over here with a hundred. Units of whatever it is we're doing into the process and the manufacturing. So hundred units goes into the state which has capacity of -- hundred. -- state with a capacity of a hundred outputs a hundred but the next state only has the capacity of point five. Next stage so this stage than outputs 25 into the next stage stage three which has capacity of fifty. At separate -- A question is if I wanna increase the output of -- manufacturing line. What do I do. When the old days what they did was they increase the -- particularly want more output which -- cram more stuff in the process. But that doesn't get the real problem as you can see I can put an infinite number of units into this stage. But -- this state only has the capacity of 25 that's -- constraint. All I'm gonna get is 25 -- beyond. No matter what -- in -- So if I want. To increase the capacity of this line and do it in a systematic and logical way. Analysts I want the output to be -- 102. Don't the first thing I would do would be to work on this second stage and I would work. So that -- -- Fifth now has a capacity of -- hundred. So my first state has a capacity of a hundred which is what I want. My second stage after the passing -- a hundred. And manufacturing line. Now looks like that's. So -- -- my manufacturing line again after I have to look at ever after have addressed the most constrained element. And I say -- now that I've increased my most constrained element. To the -- I want now this next stage stage three -- I'll put a fifty or capacity of fifty it's my most constrained state. -- -- work on this stage next. -- -- This stage. Interest the past you've -- -- -- has. But the past 200. So I get a hundred flowing through here -- going through here now I get a 112 flowing through here. This state has passed him 150 has more capacity and I don't need to do anything about that. And the last state state fire hasn't passed -- on it so now once I've increased the capacity. Of my most -- state. To our wanted to be. And have achieved output of fifty -- the and are now look at might. Next constrain state which is State's three -- -- -- fifty in this case increase that -- wanted to be. And so on and it when I'm done having increased in order of of constraint. Each stage to the level I want I now have a hundred units being in port 100 -- now. No what I want you to notice is that if I had done anything else first except open up. The capacity of states -- would have had no effect for stage two would it's still bend the constraining. Factor on the output of this process. -- the first thing you have to. Increase the first thing you have to attack. If -- most constrained. Element in whatever process. You're looking. If I had attacked the State's three -- to open up its capacity. When -- made any difference. I had to attack the most constrained element first cause that's the way I start to change this process to get the results I want. Now the kind of constrain analysis we just looked at. As applied to manufacturing line actually applies to any kind of process management process police process of fire -- really anything. To illustrate that point we go back into another police process and this case who it was the same problem when a swat team that couldn't reach a door and they went through. The root cause now this as we did before. And it came to dead ends on -- people but they did come to three root causes they thought. -- -- were at at fault and this particular in this particular case. In the tools category they determining you to -- shotgun. An attack -- category they decided it needed to develop. -- breaching tactics for the team. And the training category they decided that they needed to do some live shotgun breaching training. So which one to attack first. While none of these are really. Free or -- almost free none of them are really low hanging fruit. So if we look at -- stricken house's point of view however. It becomes apparent -- one of these is going to be the real constraint. -- we can get the shotgun. That's pretty quick to do. It doesn't cost too much from me -- thousand dollars. We can develop the tactics. That -- take too many hours on the -- part. But doing the live shotgun breaching it turns out is the constraint. Because we don't have a -- to that out we don't have the doorstep and on facilities to do that on so that is either very X. Parents of -- going to record a lot of travel or some negotiation with fellow agencies or something like that. So if we don't solve this problem we can solve this problem and this problem -- heart's content. It's still not gonna solve the big problem because this is the constraint. -- we what we would suggest is to this team they start working on this problem first. Start working on a training facility first. Get that so that. The end is in sight so that that this issue looks like it's going to be -- relatively soon and then they can start working on these other two. So that's how -- analysis would look or work. In terms of a police process or public safety process and if -- in fire -- search and rescue or emergency management -- EMS ordering Iran. The same kind of thinking. Can be easily applied to what -- you're trying to improve. Once you've identified your root causes of the problem congress -- another way you might wanna look at which -- those who caused us to attack first. Is in terms of which one occurs most often. And to do this you something that's. Usually called up -- diagram or mr. Graham just fancy words for bar chart where you plot. -- put -- causes on the X axis the frequency with which they occur. On the Y axis you just see how often these cost to show up as root causes when you have the same problem. And looking at it this -- you say what you -- -- tends to be the one that causes the problem we're trying to solve. The most often so that might make sense to attack first. So all of these three -- Attacking the low hanging fruit because it's easy -- -- to do. Using -- analysis. We using frequency analysis. That all three ways you can figure out which of the root causes you've identified. To go after first. And which of these methods you -- there's no real science to it Polly wanna look at a -- Not all three would apply in every case. And when you have more than one that applies its gonna have to use your common sense and it's it's really is fairly commonsensical. But at least he now have some cools. Some proven tools to use when you try to do continuous improvement and make yourself. Into an ongoing high performance organization. -- all of these tools. Although they're proven. -- pretty simple. So you might be asking -- -- gosh -- so simple why do we need even use these tools. When we just wing it means it's it's common sense -- let's just get together talk about it and what welcome for the resolution. Well there are reasons to use structure tools like this. In the number one is it actually forces you to go through the process remember earlier we said. The most agencies that we are aware of don't do this kind of after -- -- view as often as they should. And in many cases not as often as their SOPs or to policy -- So it forces you to do it. Another reason is these tools will open up your mind to possibilities it may not be obvious. Third reason is rather than just have a bunch of ad hoc suggestions coming. At different levels from different places you know how to structure to can actually analyze things. Better and more intelligently -- you could without structure. And finally. Doing after action reviews in this way provides documentation. Documentation from management documentation for the people and the action items. Documentation for the reasons you're doing things and at a delusional need to explain to this public safety audience -- -- things document -- is a good idea so for those for reasons. We think it's a good idea to institute these kind of tools -- after action reviews.