Ninety minutes. Within three weeks of the situation ending. Everybody who had a role, including the people who were peripheral, because they saw things the central participants did not.
Set it up correctly or do not hold it
Somebody other than the senior person runs it. If the executive director facilitates, everybody performs for them and the exercise measures performance. Any competent person who was not central to the response can do it.
State the purpose and the protection at the start. We are looking for what the system did not supply. Nothing said here goes into anybody’s file. Then hold to it, because one breach ends the practice permanently.
The senior person speaks last, every time. Whatever the leader says first becomes the frame, including appreciation, which is the most common way these get closed before they open.
Bring the log. The whole exercise depends on a contemporaneous record. Without one, you are comparing four reconstructed narratives.
The sequence
1. Reconstruct the timeline. Facts only, no explanation. Twenty-five minutes. What happened, when, who knew what at each point, using the log. Explicitly forbid why during this stage.
This is the step organizations skip and it is where most of the value is. A shared factual timeline reliably surprises people, because each participant discovers that something they assumed was known was not, or that two events they thought sequential were simultaneous.
2. Mark the divergences. Ten minutes. Where does the timeline differ from what people remember, and where did two participants hold different pictures at the same moment? Each divergence is a place information failed to travel, and those are findings before anybody has interpreted anything.
3. Four questions, in order. Thirty minutes.
What went as intended, and was that because of the arrangement or because of a person? The second answer is a finding.
What did we not have when we needed it?
Where did somebody know something that did not reach the right person, and what stopped it?
What would have made this considerably worse, that we avoided by luck rather than by design?
4. Three fixes. Twenty minutes. Specific, with a named owner and a date. Not fourteen recommendations, which is a report and produces nothing.
5. Senior person, five minutes, last. What they are taking from it, including anything about their own conduct, which does more to establish the honesty of the exercise than any stated protection.
Ask about the near-miss
The fourth question in stage three deserves particular attention because organizations almost never ask it.
Every response contains things that happened to work out. The person with the access code was reachable at eleven at night. The second failure did not occur while the first was being handled. Somebody remembered a detail that was written down nowhere.
Each of those is an exposure that a successful outcome has concealed. They are the findings most likely to matter next time and the least likely to surface, because nothing went wrong and there is no incident attached to them.
Handling the moment somebody is at fault
It will happen, and how the facilitator handles it determines whether anybody ever speaks candidly in one of these again.
The move is to convert it into a system question without dismissing it. Somebody says the notification did not go out. The response is not who was responsible; it is what would have had to be true for that notification to go out reliably regardless of who was on shift.
This is not a way of avoiding accountability. Individual accountability is a separate conversation held privately by the person’s supervisor, and it should happen where warranted. Merging it into the review destroys the review and produces a worse accountability conversation, since it happens in front of an audience.
Small organizations
For an organization of a dozen, forty-five minutes and the same sequence works, with one adjustment.
Finding a facilitator who was not involved is frequently impossible. A board member, a peer from a comparable organization, or somebody from a partner agency can do it, and the outside perspective is worth more than the familiarity that is lost.
Where the situation involved potential liability, ask counsel before the review how it should be structured and what should be written down. The answer varies, and it is better to know beforehand than to discover afterward that the notes are discoverable.
Afterward
Circulate the three fixes with owners and dates, not the discussion. Update the roles card that same week, while it is obvious what was wrong with it.
Then, in ninety days, check whether the three things were actually done and say so publicly. That single act determines whether the next review is taken seriously, and it is the step almost every organization omits.
Edited by Patrick J. Wolf, PhD