Judy Walker
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Everything posted by Judy Walker
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Ae5cb9178b012e8c67410f78c533e36cSuch a great summary Caroline. Thank you. It will be interesting to see if the PSIRF interventions Like After Action Review, which are designed to engage staff and increase psychological safe conversations, will be correlated with safer healthcare, outside of the local improvements they initiate. It would be a tough bit of research to undertake though!
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Ae5cb9178b012e8c67410f78c533e36cThank you of sharing this. It's a hard read but an important one. What happened to you will be happening somewhere today and lives and well being put at risk as a result.
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Ae5cb9178b012e8c67410f78c533e36cWonderful account of something truly transformational. Well done. Underpins the concept of "relational infra-structure" - when you get that right, lots of other good things can happen. Have you thought of doing an After Action Review of the project - to determine the specific features that supported success? Leadership is an obvious line of equiry - but what was it that "leadership" did to support success? The outcomes form he AAR could be used to guide future cross sector quality improvement.
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Ae5cb9178b012e8c67410f78c533e36cThank you for writing this. I am so sorry you had to experience this after your loss. The NHS is looking at new ways to get to learning and change and to involve those who are directly involved, but the risk of what you experienced remains. Some trusts are fearful of being open, and some staff are not trained to help organisations learn and improve but are in roles where they should be. Your account has made me think and learn. Thanks
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Ae5cb9178b012e8c67410f78c533e36cThank you for sharing this powerful account of your experience. and Thanks you for being courageous and sticking to your values and clinical professionalism.
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Ae5cb9178b012e8c67410f78c533e36cThank you very much for writing this account. I too admire your tenacity and courage in doing what is right. Being so transparent and open is new and scary for some organisations and people still so we need pioneers like yourself. The reactions I get around the country in response to using After Action Review with patients and families participating illustrates the same concerns. Some trusts are all for it, others, are very hesitant.
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Content Article
NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation. -
Content ArticleAfter 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.
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Ae5cb9178b012e8c67410f78c533e36cI echo Katherine's comments. Do take time to recharge. I worked for the NHS for 34 years and had "mental health" days off for myself and suggested them to my team. You do have the capacity to recover! And the system has a responsibility to support you in doing so.
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Ae5cb9178b012e8c67410f78c533e36cThank you for writing and sharing your insights and concerns. Pleased to hear you have found After Action Review so helpful. Ive been using it with corporate teams too to help them through the lockdown response with good outcomes. AAR is a time to make sense, to be heard and to think together about what could be improved.
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Community PostReading this dialogue made me think about the "freedom to speak up guardian" role as these people champion and advocate for the right of staff to be heard. A patient safety specialist role could have the same ethos; empowered to challenge the status quo. In other safety critical industries, they deliberately move people with this responsibility on after a fixed period so they don't "go native".
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Content ArticleThe NHS Long Term Plan highlighted several safety issues that need to be addressed: the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. This short article summarises what I have learnt about how After Action Review (AAR) can directly address the first two of these and indirectly impact on the third.
