Generic SWARM Template.docx

Endophthalmitis SWARM template:

Endophthalmitis SWARM Template.docx

Falls SWARM template:

Falls SWARM Template.docx

SWARM Charter:

SWARM Charter (1).pdf

The Patient Safety Management Network (PSMN) is an innovative network for patient safety managers and everyone working in patient safety. You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email support@PSLhub.org. 

A Swarm debrief is informed by the Systems Engineering Initiative for Patient Safety SEIPS and Systems Thinking principles, that theorise most problems and possibilities for improvement belong to the work system. Therefore, the aim of a Swarm is to understand and explore important or relevant work system factors that helped or hindered event outcomes and crucially whether these system issues are present in our everyday work. You can spend most of the debrief 'exploring WSF & everyday work' as the questions and prompts within this phase support a curious approach.

Finally, you can draw the debrief to a close in 'next steps', by thanking participants, summarising key learning and checking for understanding. Then informing participants of how you will document and escalate any important system issues or findings, so that these can inform ongoing or future improvement work. 

This work culminated in Spire being named as a finalist at the 2024 HSJ Patient Safety Awards, in the ‘Developing a Positive Safety Culture’ category. This recognised Spire’s dedication to embedding safety principles into our DNA.

Central to culture were two key enablers alongside PSIRF: a robust Quality Improvement (QI) strategy and the organisation’s commitment to the Freedom to Speak Up (FTSU) initiative, both of which were deeply integrated with PSIRF to support a positive cultural shift.

The FRAM model visualiser - The FMV allows a user to build and edit a FRAM model and to visualise it. The FMV runs as a web application in any modern web browser on any operating system. It has been most extensively tested (and therefore has the most predictable behaviour) using Microsoft Edge and Google Chrome.

Being clear about your destination is important in any journey: NHS England’s Patient Safety Incident Response Framework (PSIRF) is clear our destination is improvement, and After Action Review (AAR) is one of a suite of tools to support healthcare organisations towards systems level redesign and improvement. However, along the journey to our destination we may encounter challenges. Navigating the potholes provides a rich metaphor for capturing the complexity of interactions between humans and their environments. Although effective system (or road) design can support improvements in navigation, external factors (such as rain, traffic, and car and road maintenance) can all impact performance.

In this blog we use the pothole metaphor to highlight some of the challenges that organisations have highlighted in using the learning response toolkit, in particular AAR. The challenges described should not be viewed in isolation—many may exist at the same time and interact with each other to create new ‘emergent’ potholes. We hope that our guidance highlights the importance of recognising that AARs (and other learning response methods) are being introduced within a complex system where adaptation and flexibility is required to support improvements.

The National After Action Review Reporting Template 

NHS England’s new National After Action Review Reporting Template was developed in response to feedback from providers of NHS-funded services who highlighted the need for a standardised and simplified way to document the outcomes of AARs. The template was codesigned and tested with healthcare professionals.

The AAR reporting template supports healthcare organisations to ensure:

• AARs are reflective debriefs held in a psychologically safe space by a trained facilitator.
• Unnecessary bureaucracy in documenting the outcomes of AARs is avoided.
• The AAR conversation focuses on learning and improvement, and does not become a tick-box, compliance exercise.

Recognising that the artefacts and tools AAR facilitators are given to use influence how AARs are carried out, and that the broader organisational culture and PSIRF oversight arrangements together create a system in which AARs take place, we share our reflections on AAR implementation.

Minding the potholes

For those of you who drive a car, navigating roads with potholes is akin to what, in PSIRF terms, we call ‘everyday work.’ So what’s the link between the daily challenge for a driver of navigating potholes and for healthcare organisations who are implementing AAR? Read on.

1. Ensure your tyres are properly inflated

Our AAR analogy to properly inflated tyres in healthcare organisations means ensuring your organisation has a cohort of trained AAR facilitators (by trained AAR facilitator we mean staff that have undergone the 2-days ‘systems approach to learning from safety events’ training). Leading an AAR requires finely honed facilitation expertise. AAR facilitators need to be able to create and hold a psychologically safe space in a context where participants may hold different roles, ranks, and be from different professional backgrounds.

The psychological aftermath of a patient safety event leads to a wide range of emotions and reactions from the staff involved and the AAR facilitator needs to be able to work well in this environment.

AAR facilitators require education and continuing professional development. As one of the blog’s co-authors, Gabby, describes it, "there are the confident few and the tentative many" among trained AAR facilitators. Does your organisation have a plan in place to provide continued support to AAR facilitators, for example, a buddying system where trained AAR facilitators have opportunities to observe their peers leading an AAR before doing this themselves?

Organisations who perceive AAR as four simple questions that an untrained facilitator can ask are akin to a car with under-inflated tyres. Just like when that car hits a pothole, circumventing education for those leading AARs increases the risk that we may compound the harm for those affected. We are also less likely to get the deeper insights into ‘work as done’ that we are seeking.

2. Check your tyre pressure regularly

Tyre pressure can fluctuate due to different environmental conditions. It is important to check your tyre pressure regularly, particularly ahead of long trips to reduce the disturbance and friction caused by potholes.

What checks and balances are built into your system to check on the quality of the AAR work being undertaken? How are you getting and giving feedback about AAR experiences as well as outcomes? How are you supporting your AAR facilitators after they have attended education and training?

Ensuring you have oversight arrangements that enable you to sense check and tune in to ‘work as done’ around AAR implementation is super important. And this is not limited to AAR—it is equally applicable to learning response leads who are using other tools in the PSIRF toolkit.

3. Look ahead at the road

Looking ahead down the road from the perspective of PSIRF involves addressing systems weaknesses and improving the healthcare system. To reach that destination, you need the AAR to focus on ‘work as done’ by asking questions like, "what would you normally expect to happen?", "what got in the way of things going as expected?", not "what should have happened?"

Remember, the way we word questions influences whether we get into deeper conversations about the work system and avoid a ‘shoulda, woulda, coulda’ type conversation.

Keep the destination of systems improvement in mind and check-in that your organisation is not reverting to a counter-factual thinking conversation when AARs are carried out.

Looking ahead further down the road will also enable you to evolve the use of AARs in your organisation. At the start of your organisation’s AAR implementation journey you will probably focus on learning from patient safety events. As AAR becomes more embedded, it will evolve and be applied in other areas; for example, to understand how and why patient engagement and involvement went well.

4. Slow down

Just as careful and slow driving can mitigate the discomfort and dangers of potholes, so a careful and slow introduction of AAR will mitigate some of the implementation risks.

Apply the quality improvement philosophy of starting small and testing, which in patient safety events and healthcare contexts AARs can be most useful in. One of the 'AAR essentials' in the new national reporting template is, "AAR is a method for enabling an open and honest conversation about an event that can be used on its own or as part of a wider suite of methods". Explore how you might combine and layer AARs with other tools in the PSIRF toolkit; for example, walk throughs and observations.

Big bang implementation, where there is blanket roll out of AAR across an entire organisation, overwhelms AAR facilitators and healthcare teams alike. It also makes it more likely you will turn what is intended to be a reflective, inclusive, debriefing conversation into a bureaucratic tick-box exercise.

For those of you in PSIRF oversight roles, enacting the oversight mindset involves developing mechanisms that enable you to sense check whether your organisations’ AARs are creating the right type of conversation. By this we mean, "Are AARs supporting participants to learn and reflect?", "Do the ways in which we document and report the outputs of AARs evidence we are getting insights into 'work as done'?", "How are those affected experiencing AARs—are they perceived as psychologically safe spaces, or a tick box exercise?".

5. Leave ample following distance

The 'AAR essentials' in the new national AAR reporting template remind us that AAR is a psychologically safe space where all those present are heard and all contributions are valued equally, irrespective of rank or status. AAR creates a space to understand the perspectives and experiences of those in the room. Just like vehicles on a road full of potholes, we need to work collaboratively to safely navigate a potentially dangerous environment. We need to leave ample following distance to the car in front, and we need to ensure there is cohesion between AAR and what else the organisation is striving to achieve.

For example, are you creating cohesion between work to create a restorative just culture, human resources policies and processes, quality improvement work, quality priorities, other PSIRF implementation activity and AAR?

Or are you travelling down a road where there are many stand-alone organisational initiatives, and where leaders are focused on achieving the destination for their own initiative or project without working collegiately to create a unified approach?

Leaving ample following distance also involves recognising that you cannot solve big organisation-wide or cross-organisational sticky problems within an AAR. To ensure we avoid solutionising big problems, the new AAR reporting template contains sections which differentiate between learning and improvements that AAR participants can take away versus bigger, stickier problems which need to be escalated through an organisation’s oversight structures.

6. Don't slam on the brakes

Slamming on the brakes when driving down a road full of potholes increases your risk of a collision with the car behind.

If you hear about or facilitate an AAR that has not gone well, see it as an opportunity to reflect and refine your approach. Don’t slam on the brakes and abandon AAR as a learning response tool.

As with all the learning response tools in the PSIRF toolkit, your implementation journey will be like navigating a road full of potholes— some you will anticipate and avoid, but you cannot avoid them all. If you receive feedback that an AAR has not gone well, regroup, reflect and use the feedback received to improve your approach. Just as we learn through AARs themselves, we can learn through the delivery of AARs, especially the tough ones.

7. Hold the steering wheel firmly

Just as holding the steering wheel firmly when driving down a road full of potholes enables a driver to control the steering on a car, those leading PSIRF implementation must steer the implementation of AAR in a way that empowers staff who are AAR pioneers to lead, whilst at the same time ensuring the organisation does not drift back to ‘the old way’ of creating unnecessary bureaucracy or creating measures and metrics which could impact the quality of AARs.

We have designed the national AAR reporting template with this in mind.

The template keeps the reporting of outcomes of an AAR simple, and it has been designed in the spirit of reducing unnecessary bureaucracy.

8. Be aware of puddles

Puddles and potholes on a road are a potentially deadly combination. Puddles mask the depth, width and jaggedness of potholes. Applied to AAR implementation (and equally to the other PSIRF learning response tools), potholes hidden by puddles will emerge as you continue your PSIRF implementation journey.

In the context of AAR, creating an onerous, bureaucratic reporting burden for AARs impacts on the quality of the conversation when the AAR is carried out.

Setting a 72-hour deadline for AARs to be completed also increases the risk that staff will be excluded from the AAR conversation, and that the outputs are biased or do not capture a true understanding of ‘work as done.’

Staying true to the 'essentials of AAR' in the national reporting template that state what AAR is, and what it is not, will help you navigate the AAR implementation journey safely.

 And if at some point, your organisation hits a puddle-covered pothole please don’t abandon AAR. Just as a driver would call their breakdown recovery service, you can call on the many sources of AAR support:

• HSSIB courses
• Accelerated learning through AAR (Judy Walker)
• Using After Action Reviews: Guidance for services
• Applying the theoretical domains framework to identify enablers and barriers to after action review: An analysis of implementation in an Irish tertiary specialist hospital
• The wrong question in an AAR

One of the aims of PSIRF has been to speed up the learning process, meaning that safety could be improved, and patients informed sooner. This is happening, with 84% of learning responses taking place within 6 weeks of the event and 59% of AARs take place within 4 weeks.

There is currently widespread variation in how learning responses are arranged and who is involved in decision making about which LRT to use. Adaptation is necessary to reflect the local governance structures and to accommodate how the PSIRF implementation is being resourced, but the lack of standardisation may be a barrier to operating efficiently, especially for the ICBs and other stakeholders. It may also become a barrier to identifying and developing quality in managing learning responses. 

When exploring what is needed in the future both within their own organisations as well as outside of them, more training was the most frequently sited requirement. Support for quality assurance and effective mechanisms for collating and sharing lessons was also expressed. 

Involving patients and family members in AARs is still underdeveloped. Most respondents are being cautious about the type of involvement patients have, with the preference for informing them of the outcomes, rather than helping them participate more directly. 

The respondents have been very active in informing staff about the new PSIRF tools, hosting events, engaging with staff directly as well as by providing digital and printed materials. However, 78% of respondents when asked about how much knowledge staff had about AAR, gave a score of 4 or less suggesting that knowledge about AAR in organisations is quite limited as yet.

If you would like to see a copy of the full report or to speak to us about providing the highest standards of training for your After Action Review facilitators,  please email info@jw-associates.co.uk.