Legionnaires' disease outbreak investigation toolbox

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Lessons identified

At the end of any incident it is important, while it is still recent, to review what went well, what didn't go so well and areas where improvements could be made. This can be through a formal debrief process, where those involved work through the incident in detail highlighting their experiences and identifying and agreeing lessons which could improve the future response, once implemented. Alternatively, the review could be on a more ad hoc basis, where small groups get together, or indeed individuals, identify lessons and submit them to a central focal point who compiles the lessons into a single document on behalf of all of those involved in the response. To aid this process, it is therefore important that during the incident, individuals make a note of things that don't go as well as expected, things that cause problems or indeed things that work better than expected.

Action Plan

Once the lessons have been identified, agreed and compiled into a single document, this document needs to be converted into an action plan. An action plan is simply a table of four columns; a list of the lessons identified, how that lesson is going to be implemented, who is going to own that lesson ie ensure it is actioned and a date by which time the lesson should be completed or reviewed. This is best achieved by a formal meeting where all contributors to the lessons identified process agree how the lesson is to be implemented and who has ownership. Further meetings to monitor the implementation of the lessons may be necessary, or could be done in a more ad hoc way if one person is tasked with overseeing the overall process. Whilst this process sounds a little onerous, with only a little effort, it allows sharing of experience, improvements in processes and ultimately should make everyone's job a little easier.