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This free webinar from the Patient Safety Movement Foundation in the US is at 7.30am PST (3.30pm GMT). It takes a significant amount of work to implement a performance improvement initiative. However, typical approaches to sustainment are insufficient and lead to drift. Panellists will propose actionable recommendations to set up effective models for sustainment and systems to identify early indicators of drift. Moderator: Chrissie Nadzam Blackburn, MHA, Principal Advisor, Patient and Family Engagement, University Hospitals Health System, Cleveland, Ohio Panellists: Kristen Miller DrPH, MSPH, MSL, CPPS, Senior Scientific Director, MedStar Health National Center for Human Factors in Healthcare Joyce Alumno, President & CEO, HealthCore, President, Health Retirement & Tourism (HeaRT) Alliance of the Philippines Cristine Lacerna DNP, MPH, RN, CIC, CPH, Regional Director, Infection Prevention & Control and HEROES Program, Kaiser Permanente Sign up for the webinar

Last Friday I joined the Patient Safety Management Network where the topic of discussion was AARs – what was already known, what wasn’t, how people are implementing AARs, the benefits they’re seeing and what more is needed to help people share their experiences and useful ‘how to’ resources. Here I’ll briefly summarise this valuable discussion and the insights shared by members of the Network, which included both Patient Safety Managers and Assistant Directors of Patient Safety and Quality, with a wide range of professional backgrounds and knowledge in the topic. This is ahead of Judy Walker, a subject matter expert in the AAR approach, joining the Patient Safety Management Network meeting on Friday 19 November to share her expertise and participate in discussion with the group. AARs and patient safety Current NHS guidance on the new Patient Safety Incident Response Framework states: “An organisation’s Patient Safety Incident Response Plan should set out its approach to the different types of patient safety incident identified from the local situational analysis, acknowledging that this will include ‘do not investigate’ or ‘no response required’. An organisation must have systems to ensure the approach and tools it uses in its response to a patient safety incident achieve useful learning/insight and outline the circumstances where they are indicated – in its PSIRP.”[1] In listing techniques for responding to patient safety incidents, the guidance includes AAR as one approach to this, describing this as: “ A structured, facilitated discussion on an incident or event to identify a group’s strengths, weaknesses and areas for improvement by understanding the expectations and perspectives of all those involved and capturing learning to share more widely.”[1] This slightly differs from the World Health Organization (WHO), who define this as: “...a qualitative, structured review of the actions taken in response to an event, as a means of identifying and documenting best practices, gaps and lessons. The review seeks to identify immediate and longer-term corrective actions for future responses. An AAR can focus on a single, specific function or on a broad set of functions, covering one or more sectors involved in the response.”[2] What do Patient Safety Managers know about AARs? Knowledge and experience of AARs varied widely among the Patient Safety Managers at the meeting. Some are leading their organisation's approach to implementing AARs and are seeing strong impact in improving patient safety, with clinicians welcoming and embracing this learning and collaborative review approach. Others spoke about how they are developing their ideas and will be adopting AAR at an organisational and ward/service delivery level, while for some this was something that was coming further down the line and they wanted to find out more. The group shared their experiences, templates, successes and uncertainties. This is exactly what the Patient Safety Management Network is about: collaboration, shared learning, peer support and responding to requests for help. There was a real ‘buzz’ in the discussion, amazing for a online Teams call! So, in summary here are some of the issues discussed as well as suggestions, ideas and questions: Are people doing AARs? One Patient Safety Manager said that her organisation expects clinical staff to be doing AARs but without a structured implementation plan and training. Its therefore not surprising that staff are left puzzled at what to do in practice. The risk is that without guidance, AARs are being completed as if they were Serious Investigation forms, providing more of a description of events rather than informing learning or action. Another Network member said that they have been using AARs in reviews of delayed cancer care and that this had been working really well. They noted that AARs facilitated by the Patient Safety Managers and really embraced by clinical teams helped to capture good practice too. AARs can help to support learning from the ‘shop floor’, empowering frontline clinicians to support improvement locally as well as wider organisational learning. People are often hung up on timelines when they undertake investigations and are not looking at the ‘bigger picture;’ AARs can really help. There were concerns shared from a Network member from a major Acute Trust about them not yet implementing AARs and not having plans in place to do so. There were also some concerns about the practicalities of dong AARs at scale, for example doing AARs for each patient fall in a month. What support is needed to help use AARs to improve patient safety? Coaching skills, training and support to make sure we get the most out of AARs. Models of good practice to ensure that they are not introducing cognitive bias and the value that independent convenors can bring to this, such as an independent medic from a different clinical area providing professional challenge. Information on convenor roles (the ‘facilitator’ in undertaking AARs). Guidance on how to engage with families and manage their expectations: - before an AAR (to explain what's going to happen) - involvement of patients/families in an AAR - with the outcome and in the context of Duty of Candour, will an AAR be enough? What benefits are being seen from the use of AARs? Quicker learning and focus on action. Examples of learning from good practice. A move away from long reports that focus on descriptive detail to shorter reports that focus on learning and action. Multi-disciplinary learning and open engagement and discussion across teams. Moving away from a ‘policing model’ of investigations; focus on human working in complex environments with processes and systems, and not so hung up on timelines. Self-discovered learning by engaging in AARs; change that is owned by staff; also getting ward engagement in problem-based learning. A way to focus on Trust-wide implementation; the whole system being designed to keep patients safe. Questions of policy and governance How best to engage patients and families in AARs? To provide support, to source their views, to manage expectations (‘it’s not an investigation’). What are Clinical Commissioning Groups (CCGs) expecting from the new Patient Safety Incident Response Framework and AAR? Do CCGs want to see the detail of every investigation, AAR or thematic review and/or ‘the bigger picture’ issues emerging from these? Discussion suggested that CCGs/Integrated Care Systems (ICS) would want to see Trust-wide action plans not just those focused on individual units/Directorates. Should AARs be done on every incident or specific selection of events? For example one hospital is planning to do an AAR on every fall, whether this results in serious harm or not, while another has 200 falls a month and doesn’t have the capacity to do an AAR on every incident. What will organisation leaders expect to see from AARs? How will they be assured of the quality of the review when reports are shorter? This might be particularly of concern for AARs into deaths by suicide, where panels are used to receiving very detailed reports. Context of incidents is hugely important. Discussion was that AARs should focus on the incident but with the analysis highlighting context, causal factors and what action is needed. The need for ‘protected’ time to complete AARs. Value of appreciative inquiry and learning from what works well. Otherwise, it’s as if we’re “learning about sharks just from shark attacks”. Patient Safety Managers will have to ‘let go’ and support AARs wherever incidents take place, rather than controlling the process. Very different solutions for ward-based activity compared to theatres. The measure of success will be when there are fewer falls, for instance. How will the learning from AARs be shared within and between organisations? What is your experience of AARs? Share your resources with us During the course of this discussion many members of the Patient Safety Management Network volunteered to share their templates, presentations, training resources and guides related to AARs. These will shortly be added to the Network’s community on the hub. Do you have AAR resources and good practice to share? Included at the end of this blog is some related reading on this topic and we’d welcome further additions to the hub. If you’re a Patient Safety Manager interested in joining the Patient Safety Manager Network, you can do so by signing up to the hub today. If you are already a member of the hub, please email claire@patientsafetylearning.org. References NHS England and NHS Improvement. Patient Safety Incindent Response Framework 2020: An introductory framework for implementation by nationally appointed early adopters. March 2020. WHO. After Action Review. Last Accessed 9 November 2021. Related reading Salem-Schatz S, Ordin D, Mittman B. Guide to the After Action Review. Center for Evidence-Based Management, December 2010. CloserStill Media. Learn faster and better together: The power of After Acton Review (webinar recording). 4 June 2021. Judy Walker. How can After Action Review (AAR) improve patient safety? the hub, 23 August 2019. Judy Walker. Why isn’t After Action Review used more widely in the NHS. the hub, 1 February 2021. NHS England and NHS Improvement. After Action Review. August 2021. United States Army Combined Arms Center. The Leader’s Guide to After-Action Reviews (AAR). December 2013. WHO. After Action Review (AAR) resources. 11 November 2019.

WHO Patient Safety Flagship invites you to participate in a virtual event for the launching of the “Global Patient Safety Action Plan 2021-2030”. This global action plan aspires for “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.” The event marks the achievement of an important and historic milestone, and prominent health leaders and patient safety champions will take you through the global patient safety journey. Speakers include: Dr Tedros Adhanom Ghebreyesus, Director-General, WHO Mr Jeremy Hunt, Chairperson, Health and Social Care Select Committee, UK Sir Liam Donaldson, WHO Patient Safety Envoy Dr Neelam Dhingra, Unit Head, WHO Patient Safety Flagship Further information and registration