After the emergency response is over . . .

The goal of post-response activities is to gather and analyze information that will contribute to program improvements.

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Emergency management is full of acronyms, so following that premise, consider the acronym GIGO, for “garbage in, garbage out.” In the technology field, it refers to the concept that the quality of the output is determined by the quality of the input.

The goal of post-response activities, such as hotwashes and after-action reports (AARs), is to gather and analyze information that will contribute to program improvements to more effectively manage the next event.

Both hotwashes and AARs must have high-quality inputs and outputs to drive real change and achieve this goal.

A diligent effort

When the emergency response is over, it is crucial to diligently evaluate the plans and processes that were operationalized and the actions taken to deal with the unforeseen variables.

Following the basic emergency management program cycle of plan-train-exercise-evaluate, this evaluation process is vital to improving processes and developing response capabilities that can save lives and mitigate business and operational impacts.

Analysis is beneficial after exercises and real events, but it is even more important to have a purposeful review after a real incident when plans and teams have been put to the test. In a real response, there may be little time for deliberation, as the most trained leaders may not be available and teams will likely confront unanticipated issues.

In addition to capability development, upgrading the hotwash and AAR experience also supports compliance with the Centers for Medicare & Medicaid Services’ Emergency Preparedness Rule, first published in September 2016 and implemented in November 2017.

Each of the four main components — risk assessment and planning, policies and procedures, training and testing, and the communication plan — can benefit from better response data and documentation.

Managing hotwashes

Improving the hotwash experience and outputs is occurring in jurisdictions across the country. During the National Association of County and City Health Officials’ 2024 National Preparedness Summit in Cleveland, speakers Kristen Lundeen, MPH, MSW, LSW, CADC, public health emergency response manager, and Lisa Lerner, public health emergency response coordinator, both with the DuPage County (Ill.) Health Department, presented a session titled “Hotwashing Your Hotwash: Techniques to Gain Better Information to Improve Future Responses.”

In an interview held virtually after the conference, they discussed several factors that prompted their focus on the topic. With Lundeen’s background in psychology and sociology, her experience with techniques such as motivational interviewing is being incorporated into the emergency management program realm. Those who are in the emergency management field will likely commiserate with Lundeen’s comment that the “what went well, what didn’t go well” questioning process typically does not produce actionable information.

With multiple options available for conducting a hotwash, it can be difficult to know where to start. One may consider scaling the hotwash to the scope of the response. For a simple response event — perhaps a situation with a smaller team and a shorter duration — an electronic survey may suffice to gather the pertinent information. For more complex events — larger teams, multi-agency responses and longer durations — a more formal in-person or virtual meeting may be needed.

Surveys are convenient tools for gathering data, regardless of the extent of the response. While instituting changes in Lundeen and Lerner’s approach to hotwashes, Lerner noted that the improvement in time management was a selling point for participants who have little-to-no extra bandwidth for a hotwash meeting. They advertised surveys as a way to obtain information, and if they received good responses via the surveys, the subsequent meeting discussion could be briefer.

In pursuing improvements with hotwash questioning, Lundeen considered her experience in the counseling profession and noted that “the first thing you are taught is motivational interviewing, how to elicit change talk and how to find out the strengths of what’s going on, what do we need to change and how can we do that in a manageable way. And that’s really what after-actioning is.”

Lundeen remarked that homing in on the change language is key to finding out which improvements are needed. Lundeen and Lerner, with their team, have leaned into multiple hotwash strategies — real-time discussions to obtain the subjective metrics of how a response went and surveys for both those who want to contribute anonymously and to gather more static metrics.

As they noted, and as many have likely experienced in practice, communication is a common deficiency identified after an event. Communication is regularly touted as the top process failure in any emergency response, and it is a good example to single out when considering restructuring question prompts for a hotwash. If hotwash participants identify “communications” as a gap, much more detail is needed to identify the root-cause issue and find the right solution. Was it a process issue, like a key leader not being notified soon enough in a response? Or was it an equipment issue, such as radios not being on the same frequency? Simply identifying communications as an opportunity for improvement does not produce anything tangible to fix.

A strong facilitator is crucial for persuading hotwash participants to offer detailed information regarding their experiences, especially in circumstances when only general themes are coming forward. As Lerner remarked, a facilitator cannot just hold to the pre-identified questions verbatim. They have to be skillful in developing a rapport with the participants and creating a level of comfort so that the participants can express themselves and provide open feedback regarding their experience.

A level of neutrality is also important, in that it is best for the facilitator not to add their own commentary or bias to the discussion. This can be challenging because, when focusing on event details, it may seem like a participant did something wrong during the event. In addition to navigating the various phases of the incident, an effective facilitator provides reassurances that the information is valuable to drive process and program improvement, not to point out individual acts in moments of crisis.

It is common that an agency’s emergency manager is the default hotwash facilitator. While that typically is acceptable, in some circumstances it may be better to invite a partner agency leader to assist (e.g., a county emergency manager or another local emergency manager). For multi-agency responses, often the county emergency manager or the agency that assumed incident command of the response will take the lead in facilitating the hotwash. In complex events, it is recommended that hospitals still conduct their own internal hotwash to capture specific response details, in addition to participating in any multi-agency activity, especially if internal information cannot be shared broadly.

Lastly, in today’s emergency management environment, hospitals are regularly responding to complex events in which the staff’s own safety has been at risk and/or there is significant emotional trauma from the response. Consideration must be intentional in the facilitation, timing and participants for events such as a shooting versus a more minor incident such as flooding on a patient floor.

Hospitals likely have processes in place, such as emotional debriefings, for supporting health care workers when navigating a difficult patient outcome or other distressing experience. Post-emergency response, an emotional debriefing can also help the team overcome the stress of a patient surge or other complex event. One should collaborate with the representatives who lead these emotional debriefings to understand any nuances, such as timing and participants, prior to proceeding with the hotwash discussion.

Organizations may have internal staff, such as mission leaders and chaplaincy, who can be included in the hotwash. These leaders can actively participate in the discussion or simply offer a supportive presence to the team. During the hotwash, one should reference the organization’s information on how staff can connect with employee assistance programs for individual needs.

At the DuPage County Health Department, Lundeen and Lerner have added questions in their hotwash repertoire related to mental health screening to help identify feelings of depression, anxiety and other emotions in responders. If their survey identifies these effects, an external resource is brought in to help support the staff.

As Lundeen noted, while emergency management leaders typically focus on operational improvement planning, hotwash facilitators can help ensure health care workers are taken care of to manage burnout and compassion fatigue that is more prevalent than ever post-COVID-19. While emergency management leaders may not always have the skillset to address or manage these psychological safety issues in the moment, it may be possible to identify those who are struggling during the hotwash process and help connect people to resources.

Managing AARs

Once the hotwash is conducted, the emergency management program representative has the data to write an AAR. Transparently, it can be a challenging step to allocate time for document development, and often the next event happens before the previous event’s AAR is even complete.

The good news is, as with most documentation in emergency management, there is a wealth of templates available for constructing AARs. The most recognized resource likely is the Homeland Security Exercise and Evaluation Program (HSEEP) template.

For any template that is chosen, the following key components should be included in the AAR: description of the response scenario, including timeline, patient surge numbers and other relevant facts; whether incident command was activated; response objectives; analysis of the applicable regulatory agency’s program (e.g., The Joint Commission’s six critical functions of emergency management); detailed descriptions of strengths and opportunities for improvement; and the improvement plan.

The HSEEP template is not a health care-specific document, so sections may need to be added to include applicable information from The Joint Commission or similar agencies.

Once the AAR is written, the document should be shared with those who participated in the hotwash and anyone who has been assigned a task in the improvement plan. This is the response team’s chance to review and edit any content or tasks based on their direct knowledge from the event. It is also the team’s opportunity to see how their contributions are influencing the emergency management program.

This builds organizational trust and shared ownership and helps reinforce their commitment to the process for the follow up to the next response.

After this review is complete, the AAR can be shared with the agency emergency management committee or other applicable governing group for the emergency management program. It is common for executive or senior leaders to participate on these committees. However, if they do not, one should establish a process to document that a representative from that level has access to the AAR.

Managing the improvement plan can be challenging, and some improvement items may take many months, if not longer, to fully resolve. Any item listed as an opportunity for improvement should be identified as a task in the improvement plan, assigned to an owner, given an expected due date and categorized (e.g., is the task related to planning, training or an equipment or resource deficiency?).

The emergency manager is likely not the applicable owner for all tasks. For example, if a training deficit was identified with the emergency department, one should assign that follow up to the department leadership and/or a clinical education representative. One should rely on colleagues who are the applicable subject matter experts to determine improvements that are realistic to operational processes, available resources and interdisciplinary functions.

Through the cycle

Recalling the basic cycle of emergency management, the next step after the evaluation phase is complete is to return to planning (i.e., the emergency operations plan and related policies). As noted previously, one should complete the feedback loop across the various documents by noting these types of updates in the applicable AAR improvement plan.

From her organization’s perspective, Lundeen said they have experienced improved buy-in from other leaders in their emergency management program from demonstrating that the actions documented during a hotwash discussion have produced real changes in plans and other subsequent activities. Information from event analyses and program improvements also can be included in the annual evaluation of the emergency management program, further demonstrating continuous program advancement.

The post-response phase is an important part of the emergency management cycle. It is a crucial time for reflection and analysis that can significantly contribute to program improvements. Conducting meaningful hotwashes and developing thorough AARs will ensure that the improvements are effective and adopted into response practices so that organizations are better prepared for the next crisis. 

Related article: A post-response quick reference

Both hotwashes and after-action reports (AARs) must have high-quality inputs and outputs to drive real changes. Some further advice to gather and analyze information that will contribute to emergency response program improvements are provided below.

Hotwashes

The Federal Emergency Management Agency (FEMA) describes a hotwash as a facilitated discussion held immediately following an exercise among exercise players from each functional area designed to capture feedback about any issues, concerns or proposed improvements players may have about the exercise. The following tips can help improve their effectiveness:

• Schedule as soon as possible after the conclusion of the event.
• Include those who were directly involved in the response, including frontline staff, providers, senior leaders and other agency partners.
• Correlate the duration of the hotwash according to the duration of the response (e.g., shorter responses equal shorter hotwashes, and some hotwashes may even be accomplished via an electronic survey).
• Choose a facilitator who is a trusted leader or colleague, unbiased to participants, and one who can draw out detailed feedback even in a challenging discussion.
• Take ample notes or record the session, if possible.
• Reinforce to participants that improvements are about processes and not people.
• Ensure that participants know how their contributions to the response and the hotwash will influence the emergency management program.
• Consider the emotional needs of the participants and incorporate relevant resources during the hotwash (e.g., agency mission leaders, chaplaincy and critical incident stress management teams).

AARs

FEMA describes an AAR as a document intended to capture observations of an exercise and make recommendations for post-exercise improvements. The following tips can help improve their effectiveness:

• When in doubt, use FEMA’s Homeland Security Exercise and Evaluation Program template, which is linked in the accompanying main article.
• Include specific references to the agency’s regulatory body in the analysis of the findings (e.g., The Joint Commission’s six critical areas for emergency management).
• For multi-agency AARs, consider information that may be protected or sensitive. It may be possible to create one overarching AAR that includes a separate appendix for each agency to be “for internal use only.” In the improvement plan section, include specifics on what the improvement is, who is accountable for the change and the timeline for completion; and if a plan or policy edit is identified as an improvement, note the document name and the page where the update was made in the improvement plan.
• Allow the hotwash participants to review and provide feedback on the document.
• Establish an internal process where the document is accessible for senior leader review. 

Kathryn Quinn, MHS, CHSP, SASHE, is safety officer and emergency management manager at Trinity Health – West Region and ASHE Advisory Board Region 10 Representative based in Boise, Idaho. She can be reached at kathryn.quinn@saintalphonsus.org.