AAR in the NHS
Introduced into the NHS from the British Military in 2009, the After Action Review model has now been recommended by NHS England in the new Patient Safety Incident response Framework ( PSIRF ) as one of the key tools needed to bring about a significant improvement in the delivery of safe and effective patient care. The research evidence for the use of AAR is strong and we have considerable experience of enabling NHS staff develop the knowledge and skills required to get all the benefits.
“The organisations that will truly excel in the future will be the organisations that discover how to tap people’s commitment and capacity to learn at all levels in an organisation.”
To improve patient safety, you need to remove fear
The AAR model gives healthcare providers an evidence based approach for creating psychologically safe environments where all grades of staff are able to contribute fully, free of the fear of consequences.
When used skilfully and regularly, AAR shapes the language and behaviours of staff so they readily seek to learn from their shared experiences and recognise for themselves what they can do differently in future.
“After action reviews engender communicative processes that allow teams to better comprehend and respond in the face of danger and ambiguity.”
Blame holds us in the past, learning moves us forward
The After Action Review process does not allow blame of self, others, or “them”. It instead challenges participants to fully understand what prevented the achievement of all the expectations and what action is required to mitigate this in future. This “learn not blame” approach puts all participants in a much better position to move forward and take responsibility for making improvements themselves.
“Unlike post-mortems, the AAR is a continuing practice that is focused forward, generating lessons to be applied in the immediate future by the same people who developed them.”
All change starts with yourself
Individual staff must be fully engaged in reducing risk for patients because it is their awareness and their actions that will help deliver improvements. The AAR model joins the individuals’ learning with the organisations and creates a place for the individuals participating to learn about their own part in the action and what they need to change in future by building real clarity of the event through the experiences of all involved.
Research done by Renshaw, Tucker and Norman, looked into the benefit of using AARs to learn from patient falls, both achieved and sustained. They reported an incredible and previously unheard of 49% decrease in patient falls because those involved became more aware of what THEY needed to do to reduce the risk of patient falls. Because the focus of learning points to the individual, patients are safer from the moment the AAR is completed and participants walk out the door.
“The AAR debriefing provided the opportunity for the ward team to develop a shared understanding about possible causes for each fall and renegotiate together whether their habitual practices (norms) for falls prevention were fit for purpose in their specific local environment.”
Renshaw et al
AAR increases staff resilience
The values and professionalism of those who work in healthcare are powerful motivators, but mean staff are particularly vulnerable to self-blame and recriminations when patients have suffered harm. Shame and self-doubt may mean that internal reflections are not shared and given a reality check.
This is why AAR can make such a valuable contribution to reducing “second victim harms” by ensuring that staff are both heard and helped to see the bigger picture and the multiple causes of events.
A warning about introducing AAR
It’s important to recognise that the potential rewards of improving patient safety can be tempered by the fear of change, of taking responsibility and soured by the experience of low psychological safety in some teams. The familiarity of doing things the same as they have always been done, is quite normal at the individual, team and organisational level, especially in a “noisy” demanding environment like healthcare.
The introduction of AAR is likely to encounter challenges and will need leaders and senior clinicians who are courageous enough to act to overcome them. We will support you, bringing our first-hand experience and learning to enable you to overcome resistance and guide you through the integration process.
“The AAR Is not a meeting, but a practice”
The five essentials of a successful AAR
The Action: Trusts may define their own criteria for holding an AAR, but it is a universal highly adaptable tool that can be used to learn from any shared action .
The Participants: learning is enriched by having multiple sources of information, so AARs should include a variety of ranks and roles and engage with all the departments and functions involved.
The Four Questions: these remain the same for every AAR whether it lasts 15 minutes or 2 hours.
The AAR Conductor: a neutral and trained facilitator will hold participants in the four question journey and apply the ground rules, challenging bias and group think and ensuring all participate fully.
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