The Challenge

The Quality and Safety department of an acute NHS Trust wanted to improve patient safety outcomes and the patient experience. Several staff members already had direct experience of the value of After Action Review in achieving this after working at University College London Hospitals NHS Foundation Trust, so a Before Action Review was held in October 2020 to plan the way forward with a broad stakeholder group.

The Solution

The BAR participants decided to focus on training AAR Conductors in three therapy areas initially and identified the key requirements for educating staff about the tool and when not to use it, as well as when it would be most appropriate. The aim was that the pilot would lead to much wider roll out and  that AAR would become a part of the hospital’s culture and improve patient safety as a direct result of staff being engaged in learning together.

Between January and April 2021 four remote training days were held for 30 staff from a range of disciplines and grades. ( A necessary adjustment due to the pandemic)  In the following months, AAR Conductor Learning Sets were held online to enable the novice Conductors to learn from each other’s experience and maintain knowledge and skill development.

Approximately half of those originally trained went on to become active AAR Conductors, calling and leading AARs within their own clinical areas as well as conducting AARs to help other departments learn from events.

Seven of the AAR Conductors were educated to become AAR Conductor Trainers in September 2021, and started training others from Feb 2022 onwards, increasing the use of AAR across the whole Trust.

Alongside the training, members of the Quality and Safety team have made information about AAR available to all. Well ahead of guidance from the PSIRF, they have also defined how it can be integrated into existing ways of working to reduce risk and increase safety.  

The Result

AARs are now held for a wide variety of events across the Trust and provide a safe and productive place for staff to share experiences and to make sense together of what puts patient safety at risk. The Quality and Safety team co-ordinate a percentage of the AAR activity but many AARs are held by local teams independent of Q&S. For example, one therapy team wanted to review its service for one patient pathway and ensure its new recruits were up to speed on the service so held an AAR identifying expected outcomes and the lived reality for patients and where improvements could be made.

Newly trained AAR Conductors are given a “buddy” who has more experience to help them with their first AARs and the Q&S team have created an eLearning module about AAR for all staff to access, especially at induction, to build on their safety briefings about AAR. 

The aim now is to encourage staff to use AAR for low harm events as well as more serious ones, to capture issues before they get repeated and cause more harm.