TFD Operations Peer Review Policy

Overview

• This document outlines the TFD's policy for conducting Operations Peer Review.
• The procedures include announcing, canceling, conducting, and documenting Operations Peer Review Committee meetings and After Action Reviews (AAR).
• All TFD uniformed personnel are subject to it.
• This document replaces any earlier versions.
• The document has supporting forms like the TFD Operations Worksheet, Operations Peer Review Confidentiality Statement, Operations Peer Review Audit Form, and the TFD After Action Review Form.
• For related TFD-specific details, consult: TFD Policy 2001 (IMS), TFD Policy 2010 (High-Rise Structure Operations), TFD Policy 3510 (Mass Casualty Incident Response), TFD Policy 4004 (Hazardous Materials Emergency Response) and TFD Safety Policies: 5000 Series.

Responsibilities

• The Deputy Chief of Operations Bureau is responsible for selecting Committee Chairs, approving member selections, attending meetings (non-voting), reviewing reports, and maintaining the document.
• The Assistant Chief, Operations Bureau, or designee is responsible for being a resource for TFD policy questions, attending committee meetings (non-voting), and attending AARs.
• The Assistant Chief, Administration, or designee is responsible for serving as a resource for prevention and preparedness issues, along with attending Operations Peer Review meetings as required.
• The Medical Services Officer is responsible for acting as a resource for EMS matters and attending AARs and Operations Peer Review meetings when needed.
• The Operations Peer Review Chair is responsible for selecting members/alternates, ensuring confidentiality, maintaining confidentiality statements, coordinating audits, fact-finding during investigations, coordinating with other committee chairs/AAR Incident Commander, announcing/canceling meetings, attending meetings (non-voting), ensuring a quorum, presenting facts, ensuring recommendations align with guidelines, collecting/shredding documents, reporting findings to TFD personnel involved, and documenting meetings.
• The AAR Incident Commander is duty bound to schedule, chair, and facilitate AARs, including coordinating with the Committee Chair and/or Training Captain.
• The Training Captain or designee is responsible for providing resources for Operations training, entering meetings on the Training Calendar, and attending meetings/AARs.
• The Fire Communications Supervisor or designee is responsible for being a resource for communications issues and attending Operations Peer Review meetings as needed.
• Committee voting members must provide five days' notice of any non-attendance, attend meetings, participate unless recused, audit reports/worksheets, and maintain confidentiality.

Definitions

• AAR stands for After Action Review
• ALS is short for Advanced Life Support
• BLS means Basic Life Support.
• CAD is a Computer Aided Dispatch
• Chief Officers are uniform personnel holding the rank of Battalion Chief, Assistant Chief, Deputy Chief, or Fire Chief.
• EMIR is an Emergency Medical Incident Report.
• FCC: Fire Communications Center.
• HIPAA: Health Insurance Portability and Accountability Act.
• IRS: Incident Reporting System.
• Peer Review is a process by which committee of TFD uniformed personnel reviews the work of TFD personnel, documentation and compliance to ensure safe and effective incident management and quality customer service.
• Quorum: A minimum of three voting members/alternates, in addition to the Chair or acting Chair, must be present to hold a Committee meeting.
• Recuse: To disqualify participation in a decision due to personal involvement.
• Training Calendar: An electronic calendar accessible through Microsoft Outlook that lists events at the Training Center.

Rules

• The TFD Operations quality assurance process includes AARs, audits, and Peer Review.
• The Operations Peer Review Committee ensures safe and effective incident management and quality customer service.
• The Committee audits reports/worksheets, look at commended cases, reviews cases where TFD personnel allegedly failed to provide safe incident management, follow TFD procedures, provided good customer service, adequately documented incidents, or completed Operations worksheets.
• The Committee makes incident findings and recommendations to the Deputy Chief, Operations Bureau.
• The Committee's scope is limited to listed matters; unrelated issues are referred to the Deputy Chief.

Committee Meetings

• A Battalion Chief chairs the Committee, and it includes six members, three of whom are voting members with the other three serving as alternates.
• Any uniformed TFD member can be a Committee member or alternate.
• At least one voting member must be a Battalion Chief, one a Fire Captain, and one a Lieutenant.
• The Training Captain must attend Operations Peer Review meetings.
• Probationary personnel are not allowed on the Committee.
• Voting members serve a minimum of one and a maximum of two years.
  • The Deputy Chief, Operations Bureau, can extend a member's term.
• The Deputy Chief, Operations Bureau, can remove members due to confidentiality breaches, unexcused absences, or other reasons.
• Meetings occur quarterly, as scheduled by the Chair.
• Excused absences are permitted if the Chair is notified five days in advance.
• A quorum is required to hold Committee meetings.
• Voting members recuse themselves from discussions of cases in which they are the subject of the investigation.
• Guests can attend at the Chair's discretion, and guests under review are not present during findings/recommendations.
• Meetings must have IRS report audits and peer reviews of specific incidents on its agenda.
• The Chair can cancel meetings if there are no cases, inability of the Chair to attend, or the absence of a quorum to provide findings and recommendations.

Confidentiality

• Patient data must be redacted per HIPAA rules.
• TFD personnel details are removed from EMIRs, IRS reports, Operations worksheets, and CAD.
• Committee members/guests cannot disclose TFD personnel information, incident details, or meeting discussions.

After Action Reviews (AAR)

• AARs must be conducted soon after multiple alarm fires, significant incidents, or when requested by personnel/Chief Officer.
• The Incident Commander schedules, coordinates, and chairs the AAR.
• Participants include the Incident Commander, on-scene personnel, Assistant Chief (Operations Bureau), Medical Services Officer, dispatch personnel, and the Training Captain.
• The Incident Commander notifies the Training Captain of the AAR date/time.
• The Incident Commander ensures a short and focused AAR, establishes ground rules, focuses on WHAT happened (not WHO), encourages candor and openness, keeps discussions focused on fixable items, and maintains confidentiality.
• The Incident Commander documents conclusions and sends them to the Deputy Chief.

Audits

• Voting members must audit at least ten IRS reports/worksheets monthly, as assigned by the Chair.
• The audit compliance standard is 80%.
• The Chair distributes copies of IRS reports/worksheets and audit forms to voting members.
• The Chair proceeds with peer review when the audit score is below 80%, there's a policy/procedure/customer service violation, or the documentation is insufficient.

Peer Review

• The Committee reviews:
  • At least five working structure fires
  • Any significant special operations incident
  • Any incident referred by the State through the Deputy Chief
  • Any incident referred by on-scene personnel/Chief Officers
  • Any incident referred as a result of an AAR
  • Any incident referred as part of the audit process
• The committee makes the following determinations by majority vote for each incident being reviewed: adherence to TFD policies, quality of customer service, and adequacy of documentation.
• Committee findings are "Yes," "No," or "Cannot determine."
• If findings are "No," the Committee recommends action to the Deputy Chief.
• Recommendations are: additional training, Operations training topics, officer education/development topics, or changes to TFD policies/procedures.

Procedures - Announcing and Canceling Meetings

• To announce meetings, the Committee Chair determines a convenient date/time, requests the Training Captain to add the meeting to the Training Calendar, confirms attendance, and arranges for alternates.
• The Committee Chair notifies committee members to cancel a meeting, asks that the Training Captain cancel the meeting from the training calendar, and then notifies the Deputy Chief of the reason for cancelation.

Procedures - Conducting After Action Reviews

• The Incident Commander sets the AAR date/time and requests the training captain add the meeting to the training calendar.
• Giving advanced notice, the Incident Commander must notify AAR participants of meetings, convenes the AAR meeting, then assigns a note-taker and works with participants on ground rules.
• The Incident Commander facilitates discussion using questions about what was set out to do, what actually happened, why it happened, what will be done differently, what lessons should be shared, and what follow-up is needed.
• Lastly meeting documentation is sent to the Deputy Chief of Operations Bureau.

Procedures - Conducting Operations Peer Review

• For the Preparation phase, The Committee Chair obtains records, then redact TDF personnel information from acquired documents for the peer review meeting.
• If EMIRs are needed, patient data is redacted.
• Contacts are made as necessary to discover the incident details.
• For the Interview phase, the person submitting the concern is made aware that they are not entitled to knowing the committees findings of recommendations, The committees findings and recommendations include continuing education topics, officer education etc.
• TFD personnel being interviewed must be reminded to keep all topics discussed confidential, and not to infer about the event.
• The committee is present for a presentation of the concern and the results of fact-finding efforts. The Committee should then provide redacted copies of reports to the members. Any guest in-put is welcomed, as long as TFD personnel is not identified.
• Finally, deliberation and voting occurs, by directing all guest or members who are the subject of concern to leave the room. The discussion opens to voting members and alternates. Non-voting members may solicit comments.

Documenting Operations Peer Review Committee Meetings

• After each meeting, the Operations Peer Review Committee Chair prepares the following information, as a report and submits it to the Deputy Chief:
  • Committee members present at the Operations Peer Review Committee meeting, noting whether the member was on or off-duty
  • Names of guests attending
  • Beginning and ending time for the meeting
  • Number of incidents reviewed
  • Committee recommendations
  • Number of IRS reports and/or Operations worksheets audited
  • Number of audited documents that meet or exceed 80% standard
  • Overtime submitted to payroll