Why isn’t After Action Review used more widely in the NHS?

Summary

After Action Review (AAR) is a tried and tested, evidence-based approach that increases learning after events but, despite the clear benefits to patient safety and team resilience, its use in the NHS is still more limited than it should be. Judy Walker explains three of the barriers seen in clinical settings.

Content

Over the past twelve years, I have helped dozens of organisations in the NHS, higher education and in corporate contexts start using AAR to improve the quality of learning after events. Yet despite the proven value of AAR to patient safety and team performance,[1] AAR is still not making the impact it can and should. This short article explains some of the barriers to implementation that I have encountered during this time so that you can mitigate for them in your own context. 

In 2009, I joined a team at University College London Hospitals (UCLH) that had adapted the AAR concept from the military for use in the NHS. AAR provides a deceptively simple vehicle to structure healthy blame-free team interactions and the aim was to improve patient safety, clinical practice and team behaviours.[2] The AAR approach has since become business as usual at UCLH where it is now widely understood and frequently used.

What my colleagues at UCLH recognised so well is that AAR is so much more than the four questions you get when you type After Action Review into a search engine[3] and, thus, designed the introduction of the approach with this in mind. A paper in the Harvard Business Review[4] describes why AAR has so often failed in the corporate environment and this gives useful insights, but I have witnessed three particular challenges in the healthcare setting.  

1. Fear

The organisational and psychological barriers to being able to talk honestly about errors in multi-professional teams are accentuated by the hierarchical nature of the clinical context. Put simply, this means despite everyone’s best intention to learn from a near-miss or an unexpected event, there will be fear about being fully open in front of those more senior or junior and those from other disciplines. If we are being really honest with ourselves, we know this to be true. Fear of what others think about what we have done, and whether it will affect our standing in some way, is a universal human trait which is increased when the boss is in the room. This fear is in direct tension with the AAR concept of openness and cross-disciplinary learning and will act as a barrier to calling AARs unless leaders act as role models in AARs and set the scene by being honest and open themselves. 

 2. Blame

The emotive nature of clinical care heightens the response when things go wrong meaning the tendency to find something or someone to blame is increased. Not only do we have institutional demands pressing hard for straightforward answers, meaning we look for something obvious to blame, we also have our own human reaction to distance our self from responsibility. This traditional reaction again lies in direct tension with the very idea of AAR, where the process is not to blame but to learn. The research is clear, that in this most complex of operating environments there is rarely a single point of failure or a single individual who is to blame, instead there are multiple causes and effects, which, when better understood, provide a firm place from which to make effective changes. 

3. Responsibility

The concept of clinical professionalism is centred around the individual’s responsibility to deliver safe effective care and it is rooted in the very foundations of how the NHS was created. Clinicians are raised in the belief that they should know the answers to problems and the whole structure of career progression is based around acquiring more knowledge, research papers and letters after your name. AAR is a process of learning as a group and taking responsibility together to find out how to improve, so it is not surprising that it sits in tension with the historical emphasis on the individual healthcare professional and the value of their existing knowledge. AARs allow for the creation of new knowledge through a collaborative process. 

The joint guidance from the General Medical Council (GMC) and Nursing & Midwifery Council (NMC) on the professional duty of candour states: “Clinical leaders should actively foster a culture of learning and improvement.”[5] AAR is one of the best mechanisms to both foster and drive a culture of learning and improvement, but the simplicity of the AAR process itself should not blind you to the need to be very considered in how you mitigate and manage the barriers in a clinical setting. 

If you would like to discuss AARs further, I'd love to hear from you. Contact me at: judy.walker@its-leadership.co.uk

References

1. Tannenbaum SI, Cerasoli CP. Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors 2013;55(1):231-45.
2. Walker J, Andrews S, Grewcock D, Halligan A. Life in the slow lane: making hospitals safer, slowly but surely. J R Soc Med 2012;105(7):283-7. doi: 10.1258/jrsm.2012.120093.
3. NHS Improvement. Online library of Quality, Service Improvement and Redesign tools: After Action Review.
4. Darling M, Parry C, Moore J. Learning in the Thick of It. Harvard Business Review: July-August 2005 issue.
5. Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour. June 2015.

Read Judy's previous blog: How can After Action Reviews improve patient safety?

About the Author

Judy is a subject matter expert in the After Action Review (AAR) approach and over the past ten years has been instrumental in developing AAR for use in the NHS, higher education and corporate environments. After 35 years working in the NHS, in a number of roles, she has recently joined a private consultancy to help a wider audience gain from the AAR approach.