NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) this spring, heralding a significant opportunity to improve patient safety, in part because it will recommend the use of After Action Review (AAR). This article explores why AAR makes such a valuable contribution and explains how the NHS can prepare for using it effectively.

Quality not quantity

The way in which clinical incidents are responded to in healthcare settings has changed significantly in the past 20 years, yet the improvement in patient safety has plateaued. A 2019 meta-analysis highlighted that around one in 20 patients are still exposed to preventable harm, so the new approach to responding to incidents is to be welcomed.

Piloted by NHS England in 18 healthcare settings last year, the PSIRF sets out a broader, more proactive approach that prioritises the quality of investigations over quantity and creates the expectation that “ alternative  proportionate responses” for learning, that include staff, patients and their families are used far more widely. After Action Review is one of those approaches recommended in the PSIRF

My previous boss, the late Professor Aidan Halligan would be delighted as he pioneered the introduction of AAR into the NHS in 2009 when he was the Director of Education at University College London Hospitals NHS Foundation Trust (UCLH). He had witnessed its power to improve patient care after seeing it used in military field hospitals in Afghanistan.

But just how does AAR work to achieve this?

Proven efficacy of AAR

One of the best pieces of research about the use of After Action Review describes the mechanism of change. It is the personal and active engagement required by participating in an AAR that produces a different and more impactful type of learning to the traditional passive experiences such as clinical investigations. These are done to people, whereas AARs are done with and by people.

This meta-analysis of 46 research papers into AAR carried out in 2013 by Tannenbaum and Cerasoli showed that “Organizations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs (AARs)”.

There are four main reasons why AAR can make such an important contribution to improving patient safety:

  1. Active (vs passive) self-learning

After Action Reviews are a form of emergent learning in which individuals are actively involved in self-learning and self-discovery and build their own understanding of how to improve performance. This creates the conditions for more lasting change than receiving feedback or someone else’s interpretation of causal factors.

  1. Developmental (vs. administrative) intent

The developmental, nonpunitive focus of an AAR creates psychological safety and fosters an environment that encourages listening, honest information exchange and perspective taking and maximises the learning from experience. Participants in an AAR are not being told what to do differently, they are instead developing the concepts themselves.

  1. Specific (vs. general) events

Reflecting on specific incidents allows for a deeper examination of particular actions at the individual, team and system level, including both human and process factors, and allows for the creation of highly relevant action plans from the learning that takes place.

  1. Multiple (vs. single) information sources

Hearing from others directly involved in the incident allows for a more diverse and complete account of what occurred.  This leads to learning about the bigger picture context for the individuals concerned and creates the opportunity for understanding the connections between one’s own actions and those of others, and the context in which all were working.

All these elements mean that patients are safer from the moment the AAR is completed as the individual participants have learnt for themselves what needs to change. Wider system and team changes arising as a result of the learning in the AAR will be initiated with greater ease because people understand why improvements are required.

Essential preparation for using AAR

Our long experience of helping NHS organisations to use and embed AAR have taught us that there are two key factors for its successful implementation:

  1. The organisational readiness to use AARs effectively.

The PSIRF pilot phase last year has started to raise awareness and created some of the organisational readiness required to use AAR regularly in the NHS, and hopefully more guidance will be provided once the full document is published in a few weeks’ time. Our clients in large hospital Trusts who are already using AAR successfully, have all found that a sustained approach to communicating its introduction is required. As this article outlines, there are some perceived barriers to AAR in clinical settings so it’s vital for staff to feel informed about the process and understand when best to use AAR.

  1. The knowledge and skills to expertly conduct the AAR

Whilst organisations like UCLH that have embedded AAR into their culture can use AAR informally as a shared approach for team learning, the most impactful changes in patient safety still rely on the skilled facilitation of an AAR Conductor. Maintaining psychological safety and holding participants in the self-discovery and developmental process is a skill which we taught to 230 new AAR Conductors, 78 of them in the NHS, last year. Please get in touch to find out more about our training services.

I hope the opportunity that the PSIRF creates for the widespread use of AAR will mean the rate and quality of learning from patient safety events will increase significantly and Professor Halligan’s legacy can live on.