After Action Reviews as a continuous quality and patient safety improvement tool - Transformation Partners in Health and Care

By Alkmini Petraki, Assistant Director

NHS England defines patient safety as the ‘‘avoidance of unintended or unexpected harm to people during the provision of health care.’’

Mistakes in healthcare can lead to potentially life-threatening or life-altering risks to patient safety. As such healthcare providers are tasked with a challenge of the upmost importance – to create and maintain an environment where mistakes are avoided wherever possible, caught early and managed effectively when they do happen, and where lessons can be learnt constructively so learning can be applied in the future to avoid them being repeated.

Embedding learning to inform patient safety incident response

The new Patient Safety Incident Response Framework (PSIFR) has been launched to support the development of an effective patient safety incident response system in the NHS.

The PSIRF is mandatory for all services provided under the NHS Standard Contract; acute, ambulance, mental health, and community healthcare providers, and including maternity and all specialised services, across the country.

Whilst investigations into patient safety incidents are a part of the process, PSIFR looks to a broader approach with respect to patient safety, creating a shift to use of a range of learning response tools focusing on:

compassionate engagement and involvement of those affected by patient safety incidents
application of a range of system-based approaches to learning form patient safety incidents
considered and proportionate responses to patient safety incidents
supportive oversight focused on strengthening responses system functioning and improvement.

In this new framework, After Action Reviews (AAR) are one of the methods endorsed for learning from patient safety incidents to inform improvement, generate insights from the various perspectives of those involved in the event, and to learn from the positive outcomes as well as the incidents.

The AAR mindset

PSIFR holds as much a challenge as an opportunity in the world of patient safety. It invites a new mindset of how to embed AAR as a learning tool, knowing when to use it (such as when there is a gap between what was expected and what actually happened) and enabling individuals and teams to learn by empowering them to put that learning into action, review it again and continuously improve.

We know how rich in knowledge teams of healthcare professionals are. AARs are all about taking a personal stake for continuous improvement, looking at past experience with the intent of informing future action. By sharing everyone’s expectations before and experiences during the event in review, AARs unearth valuable insights into the different perspectives and provide safe spaces for team members to come together as a group of equal learners, leaving hierarchy and blame outside of the room, to look at the gap between their personal and collective expectations and actions, and develop new solutions.

Smiling woman with red headscarf using a pen to write on a flipchart

Teams who use AAR routinely have the ability to reflect and learn together, building excellent problem solving, flexible thinking and capacity for continuous improvement.

In the past year, we have supported numerous trusts within and outside of London with designing and delivering comprehensive AAR conductor development programmes. Those programme included training; post-training bespoke support such as action learning sets and mentoring; setting up communities of practice, and designing communications materials and advice to sustain the AAR approach.

AARs help team members to come together as a group of equal learners, leaving hierarchy and blame outside of the room

As someone who has been using, leading and supporting others in using AARs for several years, I’ve seen how teams that use AAR routinely not only develop the ability to reflect and learn together effectively, but take on a learning mindset. Teams can shake off judgement and evaluation, and develop skills around problem solving, flexible thinking and continuous improvement which go far day to day.

If you are looking to build team resilience and performance and create a sustainable learning culture, then talk to us.

TPHC are experts in independent AARs and BARs. We offer:

Expert conductors
After Action Review Conductor Development training
Conductor development
Organisational development to embed AAR practice.