Patients and the After Action Review
Guidance for Healthcare Providers: August 2023. By Judy Walker
“The PSIRF supports the development of a patient safety incident response system that prioritizes compassionate engagement and involvement of those affected by patient safety incidents……‘Those affected’ include staff and families in the broadest sense; that is: the person or patient (the individual) to whom the incident occurred, their family and close relations.”
The PSIRF supporting guidance “Engaging and involving patients, families and staff following a patient safety incident”1 presents the moral and logical arguments for engaging with those affected by a patient safety incident and involving them in a learning response. This article builds on the guidance given to describe how After Action Review (AAR) can be used to ensure patients and their families and carers can and do make a significant and meaningful contribution to the learning process.
(The term “patient” will only be used below but will imply family members and carers where appropriate.)
The benefits of informing patients and inviting participation in AAR
An integrative review published by Luikka et al 2 synthesized knowledge, theory and evidence regarding action after Adverse Events, from literature published in the last ten years. The results highlighted how “first victims” wanted apologies from the healthcare organisation (HCO) to include information about how the HCO would learn from the adverse event and make changes. “First victims had often lost trust in HCOs. Open discussion about what went wrong, and why, can be the first step to understanding and forgiveness. One reason for a loss of trust may be a lack of transparency after Adverse Events. First victims should be convinced that everything possible is being done to avoid a similar situation in the future.”
When patients are informed of the outcomes of an AAR and the actions arising as a result, some of these first victim information needs will be met. This is certainly the experience of a number of NHS Trusts which have initiated this practice already. When patients are invited to contribute to the AARs themselves, the level of transparency is significantly increased and the potential for understanding and forgiveness is therefore much higher.
When patients are involved, as opposed to informed, whether present in person or not, the quality of learning that can take place is potentially even richer. The description of the patients’ expectations and experiences brings depth and realism to the patients’ context that is incredibly educational for the staff participating. Similarly, when patients hear the staff’s expectations to deliver safe effective care and what actually happened, often out of the patients’ sight, they are also educated about the staff context and their efforts to do the right thing.
When not to invite patients to participate in an AAR
1) When it’s not appropriate for the patients’ emotional context
Patients have to trust those employed in healthcare to provide a service to help them in whatever way is needed, often when they are at their most vulnerable. When experiences do not meet patients’ expectations and trust is weakened or lost, many different responses are possible. The Canadian Patient Safety Institutes’ 3 study of partnering with patients explains that the impact on those coping after harm in healthcare is a form of grieving. The person who has been impacted by the harm mentally processes the loss associated with the harm in a way that is similar to other loss-related experiences. In moving through the process of coping, some, but not all, will find themselves sufficiently healed and will be able to collaborate in activities like AAR without being re-traumatised or further harmed by being part of this work. For others, they may not be emotionally ready and participation in AAR will not be appropriate and other forms of support should be offered.
2) If the staff directly involved have been significantly affected by the event
As well as “first victims”, some adverse healthcare events will also have “second victims” amongst those employed by the organisation. Individuals may feel personally responsible for the patient outcome. When staff feel isolated or unsupported after adverse events, feelings of distress, self-doubt and fear are common with consequences for physical and mental health as well as performance at work. Some studies, but not all, suggest that debriefing approaches such as After Action Review can mitigate second victim harms, because isolation and rumination are reduced by the inclusive process of the AAR, so when deciding whether to invite patients/family members to participate in AARs, it will be necessary to also consider the emotional needs of the staff directly involved.
3) When an individual’s action or inaction is the main cause
It may not be appropriate to invite patients to participate in AARs where the topic is one where an error was made by an individual member of staff. AARs are about “what” not ‘who” and considerable learning about the context and system in which an error occurred will provide valuable knowledge for the organisation but it is likely to be of less value to have the patient present.
Planning for patients’ participation in learning
It is vital that the approach to involving patients recognises that there is no one way that will suit all, and each situation should be tailored to each context. Each individual involved in an incident is likely to respond differently and no response is “wrong”. However, there are some questions that should be asked along the way to help guide the approach to be taken.
Informing or involvement?
Shall we inform the patient that an AAR has taken place or shall we involve them in the AAR process?
The Duty of Candour legislation in the UK requires that patients are notified and apologised to about any harm that was caused, and informed of the actions planned to mitigate risk in future. Yet organisations do not legally have to tell patients about incidents that caused a “low level of harm” (e.g. minor or short-term harm) or “near misses”, so patients will not always need to be informed if an AAR is taking place. However, if the incident does reach a threshold for the Duty of Candour, then there are two options available:
1) The healthcare provider can inform patients once an AAR has taken place, describing its aims and process and the outcomes and actions arising as a result. The chart (Link below) suggests some steps taken before and after this.
2) The healthcare provider can consider involving the patient and/or family/carers in the learning process itself. There are two options within this consideration.
Shall we invite the patient to contribute to the AAR or to attend the AAR?
2a. Inviting the patient’s/family to contribute to the AAR means informing them of the purpose of the AAR process, and the value of the patient’s contribution to the learning process. Contributions could take the form of a structured interview prior to the AAR to identify their responses to the four AAR questions which is then written and read out during the AAR so that staff hear the patient’s expectations and experiences along with their ideas about barriers and enablers, and their own learning and ideas for improvement. The learning cycle is then completed for the patient with a meeting, call or letter to share the learning identified and actions agreed as a result of the AAR.
2b. Inviting the patient/family to attend the AAR means arranging for them to participate fully in the AAR held with staff.
This option has the potential to lead to very powerful learning for all those involved as both staff and patients get to see a much more rounded picture of the incident being reviewed and learn directly from each other’s experiences. However, it is also the approach which needs most effort to create the conditions for success.
- For a patient or family member to participate in an AAR will require more than one conversation about what an AAR is and what to expect during one. Written material and videos may assist in this preparation phase.
- More than one conversation may also be required for staff to feel comfortable about patients or family members participating in an AAR. Assurances on the legal context for the AAR may be required.
- Often it is advisable to hold two AARs – the first with staff only, so that they can review the whole event, identify their own learning and prepare to make their contribution to the second AAR in an appropriate way with the patient present.
- The AAR Conductor should be a trained, experienced and confident practitioner, able to manage the complexities of an AAR of this type.
- An additional member of staff solely to support the patient before during and after the AAR should be considered.
Positive indicators for inviting patients to participate include:
- The staff participating have previous experience of participating in AARs
- The patient responds positively to the idea
- Several contributory factors were involved
- There is familiarity with the AAR process within the organisation
- Staff trust and value AAR for healing and learning
- There is a trained and experienced AAR Conductor available to lead it
- No legal proceedings are likely
A sample patient information leaflet about After Action Review
Please click on the link here to see a sample patient information leaflet, for you to adapt to your circumstances. We have highlighted areas where local detail must be added.
Please click on the link to download the leaflet. Information about AAR for patients, families and carers
A visual guide to involving patients in After Action Review
Please click on the link here to see a checklist of how to include patient in After Action Review. This is designed to complement NHS England’s’ PSIRF Guide Part B Engagement and Involvement process 4.
In summary
The effectiveness of the After Action Review process comes through the voices of those directly involved, that help build a vivid 360opicture of the action for all those participating. This enables them to learn for themselves what contributed to the outcomes and to identify their own learning and the improvements needed for the future. Patients are a vital voice to include in this process, enriching the learning for all and benefiting future patients, whilst also fostering recovery and healing for the individual patients. As healthcare providers mature in their AAR practice, the third option of full participation will be an important step to achieving the gold standard of patient participation in learning. Until then the first two options should be built into each organisation’s patient safety response plans.
References
1. Patient Safety Incident Response Framework Supporting Guidance. Engaging and involving patients, families and staff following a patient safety incident. NHS England V 1 August 2022. https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-2.-Engaging-and-involving…-v1-FINAL.pdf
2. Action after Adverse Events in Healthcare: An Integrative Literature Review. Mari Liukka et al. Int J Environ Res Public Health. 2020 Jul; 17(13): 4717. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369881/#
3. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute. https://www.patientsafetyinstitute.ca/en/toolsResources/Research/commissionedResearch/HarmtoHealing/Pages/default.aspx
4. Engaging and involving patients, families and staff following a patient safety incident. Engagement and Involvement Process. NHS England V 1 August 2022. https://www.england.nhs.uk/wp-content/uploads/2022/08/PSIRF_Report_PartB.pdf