Search the hub

Judy Walker Associates are hosting a training day in London on 2 October for individuals, rather than groups to attend. We’ve been receiving requests from people in primary care, independent providers and previous clients for individuals to access our professional development for AAR Conductors, so are happy to accommodate. Participants will get live AAR practice and feedback, learn about the Five Switches of advanced facilitation and understand how to involve patients and families successfully in AARs. Please get in touch and we can send you a flyer [email protected]

An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). The morning will be a hands on interactive masterclass which will develop your skills in conducting an AAR using simulated case study AAR examples and facilitated discussion. The afternoon will focus on case study sessions from experts who are using AAR in practice. Topics will include AAR under the Patient Safety Incident Response Framework (PSIRF), walkthrough case studies of AAR in action, the role of human factors in AAR and delivering change. There will be an extended focus on informing and involving patients in AARs in line with national guidance “Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation.” NHS England. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/after-action-reviews or email [email protected]. Follow the conference on X @HCUK_Clare #AfterActionReviews hub members receive a 20% discount. Email [email protected] for discount code.

An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). The morning will be a hands on interactive masterclass which will develop your skills in conducting an AAR using simulated case study AAR examples and facilitated discussion. The afternoon will focus on case study sessions from experts who are using AAR in practice. Topics will include AAR under the Patient Safety Incident Response Framework (PSIRF), walkthrough case studies of AAR in action, the role of human factors in AAR and delivering change. There will be an extended focus on informing and involving patients in AARs in line with national guidance “Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation.” NHS England For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/after-action-reviews or email [email protected] Follow on Twitter @HCUK_Clare #AfterActionReviews hub members receive a 20% discount. Email [email protected] for discount code.

An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR Register hub members receive a 20% discount. Email [email protected] for discount code.

An After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email [email protected] Follow this conference on X @HCUK_Clare #AfterActionReviews hub member receive a 20% discount. Email [email protected] for discount code.

Since the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform  Audience:   PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies.   Presenters:   Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register

An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email [email protected] for the discount code.

This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register

This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register

This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register

This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register

This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents. Autumn marks the deadline for all NHS trusts in England to transition to PSIRF, so it was fitting that our PSMN meeting on 1st September dealt with some of the key issues the new framework is presenting. Patient safety colleagues from a wide range of organisations shared their reflections, concerns and questions about the complex and pressing issues they are facing as they seek to adopt PSIRF’s new approaches to patient safety incident responses. There were rich discussions about variation in how trusts are implementing the framework, the resource implications of meeting the expectations of NHSE regarding PSIRF, how patients engage with the process and who should work with them. Perhaps the most important question that was discussed was about the purpose of patient safety investigations—families may have very different ideas to managers or incident investigation teams about why a loved one’s death should be investigated, and that can hugely affect how they respond to and experience the process. What are the implications of increasing engagement with families and patients? PSIRF introduces a range of new approaches to incident investigation, aiming to make the process shorter and simpler, more collaborative and transparent, and easier to implement learning from. Trusts’ existing patient safety structures and teams will need to adapt to significantly different ways of working under PSIRF. One of the key topics was how to highlight and deal with the consequences of these changes, some of which have been predicted and some of which have possibly not yet been considered by NHS England and individual trusts. Here are some of the implications that members highlighted: There is a resourcing and capacity issue linked to the increased work involved in engaging with families. For example, some organisations are separating the role of engaging with patients and families from that of undertaking investigations, to reflect different staff positions, experiences and skill sets. Across some organisations there is a huge gap in family liaison and support, and that extends to PSIRF. This is a significant resourcing issue that needs to be addressed, as without adequate communication and support, investigations can be very distressing for patients. Different ways of working will require changes and updates to trusts’ technology. For example, some trusts are designing trackers to record and monitor engagement with patients and families by multiple staff members. While this should improve communications between staff and patients, trusts may need to invest in digital and other solutions to make sure systems are reliable and that staff know how and when to use them. Does the language and approach of PSIRF create barriers for patients? The discussion then moved on to the fact that how we engage with patients and families can compound the harm they have already experienced. Working with harmed patients isn’t easy and needs the right people, equipped with right skills and the right resources. Many members voiced the need for more guidance and training for all clinical staff, as PSIRF means that their role in investigations and patient engagement is changing. For example, some organisations are updating their Duty of Candour policy to reflect the requirements of PSIRF, and these changes will affect all clinical staff. During the discussion, several members pointed to incidents where families had found the approach and language of PSIRF difficult, or even offensive. There was some discussion about how the language used is a barrier to patient engagement, with names and descriptions in the framework laden with what is being seen as NHS jargon such as ‘learning leads’ and ‘patient safety partners’. Members pointed out that this language is inaccessible and doesn’t make it easy for patients to understand what’s going on in the investigation process. One member suggested learning from the way the Parliamentary and Health Service Ombudsman has used accessible language in its new NHS Complaints Standards. Several members reported instances where families had found the language of PSIRF insensitive. For example, one family member had told a member of staff, “my mother’s death is not a learning opportunity.” Perceptions that the investigation process is detached from the reality of a person’s lived experience can lead to difficulties in maintaining supportive and positive relationships with patients and families. It highlights a need to consider whether the language used in the implementation of PSIRF is adequately compassionate and respectful. We also talked about when the best time to involve patients in different PSIRF processes is. For example, one member pointed out that if you involve patients in an After Action Review (AAR) too early on, then you won’t have any answers for them, and this can be frustrating for everyone involved. On the other hand, conducting an AAR without the patient won’t include the patient's direct insight and might be seen as ‘rehearsing the truth’. This can undermine trust in the transparency of the investigation. We also looked at the resources and literature available for patients engaging with PSIRF, and the general feeling was that there is a big gap here. There is no guidance from families from NHS England, and while some excellent resources have been produced by the Learn Together collaboration, they are quite lengthy, which may put patients off. It was suggested that a summary version of the resources would be a helpful tool to offer patients. What’s the purpose of patient safety investigations? The issues we looked at around the language of PSIRF led on to a broader discussion about why we investigate, and whether PSIRF is aligned with patient views on this. PSIRF places a big emphasis on learning from patient safety incidents, which is clearly vitally important for improving patient safety. However, patients who have been harmed or people who have lost a loved one to avoidable harm are likely to have different reasons for wanting an investigation. The family member previously mentioned, who did not like their mother’s death being referred to as a ‘learning opportunity’, did not see organisational learning as the primary purpose. Patients and families may be looking for: a sense of justice and, in some cases, compensation. compassionate support and clear information on what happened to them or their relative. assurance that changes will be made to prevent future harm. This is a strong motivator for most patients, but it may not be the only reason they want to be involved in the process of investigation. It was also pointed out that the proportionate approach that PSIRF promotes presents us with a big gulf in the nature and approach we take to patient and family engagement. The level of engagement will depend on the severity and impact of avoidable harm, meaning patients involved in incidents that don’t reach the threshold for a patient safety incident investigation (PSII) may not receive the answers and support they need. Staff engagement and support for patient safety specialists As well as the challenges PSIRF presents in terms of patient engagement, the new framework will also require buy-in from staff right across the organisation. Some members shared concerns about attitudes they had encountered in front line clinicians and patient safety leads. For example, it was reported that some doctors are taking the view that if no AAR is submitted, they don’t need to have a Duty of Candour discussion with patients or families. One very important question we discussed was what additional support might be needed for staff who conduct investigations or work in patient safety roles. Exposure to traumatic events and awful harm, day in and day out, is painful and causes harm in itself. There is a clear gap here; dealing with patient safety incidents can be emotionally draining, and we talked about the need for clinical supervision and psychological support for staff. At past PSMN meetings we have discussed at length the need to provide support and resources for harmed patients and their families. It is an important area that we will return to at future meetings. Variation between trusts The key theme that ran throughout the session was variation in how different organisations are implementing PSIRF. Each organisation’s culture and commitment to patients and family involvement will be an important factor in how PSIRF is implemented. While some organisations have a strong base on which to implement PSIRF patient engagement recommendations, others don’t. Some of the key variations discussed include: different practical approaches to engagement. Some trusts will have informal discussions with families, while others undertake more formal reviews and investigations. a wide range of structures across patient safety teams, with roles carrying different responsibilities from trust to trust. differences in how tools are applied. For example, some trusts are using AARs to assess how effective the investigation process is, while others are using them as a learning response directly. Some trusts are involving patients directly in AARs, while others are using their Patient Engagement Leads as the patient representative in the process. Patient Safety Partners have different levels of involvement in learning responses. PSIRF was deliberately designed to allow trusts to adapt their approaches according to their own contexts, which means that variation is an inevitable part of PSIRF implementation. However, members of the PSMN are expressing concern about how this will exacerbate inequities for patients based on where they happen to live—an incident that qualifies for an AAR in one trust may not qualify in others. Reflections on the way forward These wide-ranging issues feel like a lot to try and deal with while doing the day-to-day work of patient safety management. But as one colleague pointed out, there has been little funding or training on these complex issues, and members shouldn’t be too hard on themselves. There is a long way to go before PSIRF makes tangible improvements to the methods and outcomes of learning responses and incident investigations, for both patients and staff. It was highlighted that research and evaluation funding to consider dissemination and implementation is available for another year and members should consider how they might access and use this to look at tackling some of these key issues. Joining the Patient Safety Management Network Do you work in patient safety and want to join the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected].