Session 15: Activity 2 Lessons learned Facilitator notes: Legionnaires’ disease: Risk assessment, outbreak investigation and control Session 15: Activity 2 Lessons learned ECDC, 2012

Why review and identify the lessons learned? An incident is an opportunity for: Policies, guidance and plans to be tested in real time To learn what happened To understand why an incident happened the way it did What worked and what didn’t work to be identified In order to maximise the learning then the knowledge that is extracted and recorded should be carried out in a formal manner and shared Reviews help retain learning from what happened and understand why it happened, look at what went well, what needs improvement and what needs to change

Running a review Involve all the key players and should be conducted as soon as possible after the incident. The review should enable the players involved to go through what happened in the incident It is important to focus on improvement and to ensure that any mistakes or areas of poor practice that are identified can be turned into learning opportunities It is essential that there is trust and openness and that it is a learning experience rather than an attempt to lay blame

Running a review (continued) An independent facilitator may be useful to help draw out answers, insights and issues, and to ensure that everyone contributes. It should be structured as an informal session to try to achieve agreement on What was supposed to happen? What actually happened? Why were there differences? What did we learn? What are the lessons for next time?

Running a review (continued) More probing questions might include: What were we trying to do? What were the objectives and deliverables? What was actually achieved? What went well? What could have gone better? Why did it happen the way it did? What did we do? What would we do differently next time? How does this affect the next stage? What needs to be disseminated to whom and how?

Running a review (continued) Throughout the review process comments and feedback should be invited. This will help the players learn as much as possible before the team disbands. Decide how the new knowledge is going to be incorporated into a future response The review outcomes are normally captured during the session, on flip chart paper or electronically, depending on how the information will be used. To inform future work, ensure that everything has been properly documented and stored or published before formally closing a project.

Facilitator notes: Acknowledgements The creation of this training material was commissioned in 2010 by ECDC to Health Protection Agency (UK) and the University of Chester (UK) with the direct involvement of Louise Brown, Janice Gidman, Emma Gilgunn-Jones, Ian Hall (on behalf of the ECDC Legionnaires Disease Outbreak Toolbox Development Group), Tim Harrison, Rob Johnston, Carol Joseph, Sandra Lai, John Lee, Falguni Naik, Nick Phin, Michelle Rivett, and Susanne Surman-Lee. The revision and update of this training material was commissioned in 2017 by ECDC to Transmissible (NL) with the direct involvement of Arnold Bosman and Kassiani Mellou.