The sinking of the Herald of Free Enterprise, the Clapham rail disaster and the Kings Cross fire are just three of a grim list of tragedies. But, as Dr Shepherd writes, “Few, if any, of these disasters could exactly be called an accident. They almost all exposed major systems failure… Each resulted eventually in significant improvements, when emotions were calmer and the often multiple, interconnected causes had been unravelled and analysed.”
One of the most telling points he explores is that “Pathology learned a lot from them about how to deal with mass disasters – and so did I. It was the lessons of this watershed era that enabled us to cope efficiently with the terrorist horrors of the 2000s.”
This is exactly what we like to believe has happened as part of the disaster recovery process, but it feels reassuring to have it confirmed by such an expert. Hope is restored when public enquiries take place following major disasters, and benefits do indeed follow. We need to be reminded that the political hiatus that public enquiries often cause, doesn’t last nearly as long as the benefits to society.
It also reminds us of what it might feel like if we were a patient or family member when treatment or care has gone badly wrong or were a member of a team who has spent many days trying to rescue a business after a crisis. As part of the disaster recovery process, we want to know that learning has taken place by those in charge, and that this has been converted into concrete action to improve the future. Such reassurance can play an important part in reducing stress and restoring hope as we are comforted by the prospect of such misfortunes not being repeated.
Whilst the scale and processes of a public enquiry are not directly comparable to an After Action Review, there are numerous similarities. This need to be assured that change will indeed arise as a result of an AAR is a significant one, because participants in an AAR attend with hope that their contribution will be both valued and valuable in bringing about improvements in that context. And, just as the public’s trust in public enquiries as a worthwhile investment of time and money depends on what happens as a result of the findings, so people’s trust in the AAR process is linked to their perception of the changes that happen as a result of the AAR.
During the year ahead, many NHS healthcare providers will be introducing After Action Review as their main Learning Response Tool, to increase the rate and scale of learning after patient safety events. And, while the term disaster recovery may be overblown in this context, the importance of AAR in restoring hope should not be underestimated. The key is to provide reassurance and build trust in a better future. As well as ensuring people are trained to lead successful AARs, there are three steps healthcare providers should take:-
1) Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs
2) Ensure patients and family members are provided with specific information about how AARs prevent future harms
3) Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.
Just as Dr Shepherd observes in his excellent book, the long-term impact of how we learn from failures should not be underestimated. Each AAR has the potential to bring about important and lasting change, even in the simplest of ways.