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Over the past ten 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 has still not made 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 engine3 and, thus, designed the introduction of the approach with this in mind. A paper in the Harvard Business Review4 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?

In conclusion, EMS colleagues and organisations may need support to embrace opportunities from case-based learning, but research is also needed to explore the wishes and opinions of bereaved families regarding the dissemination of any case-based lessons that need to be learned.

AAR is a deceptively simple process for learning from any every day or exceptional 'action', which takes the individual expectations and experiences of the same event to build a shared mental model of what happened and use this as the basis for learning and action planning. To be successful it is essential that AARs are led by a trained AAR 'Conductor' who uses a defined four-question process and a universal set of AAR 'ground rules' to create a safe learning environment. The other vital component, which is often missing, is the organisational context in which the AARs take place. This needs to be set up to support the AAR approach to learning with leaders championing the process and the practice and believing in the value of organisational learning. “The After Action Review has democratised the Army. It has instilled a discipline of relentlessly questioning everything we do. Above all, it has re-socialised many generations of officers to move away from a command and control style of leadership to one that takes advantage of distributed intelligence.” Pascale, Millemann and Gioja, 20001 We can learn much from the military’s use of AAR. The problems created by its hierarchical structure are similar to ours in medicine, especially the fear of the consequences of speaking out and voicing a different opinion to your superiors. Research confirms that junior staff are often reluctant to question the direction or decisions of their seniors, even when they feared patients were at risk of harm.2 Fear of the consequences also limits open and honest reporting of incidents, restricting the potential gains of learning at the system-wide level and at the local level. Yet consistent and widespread use of AAR in battlefield and training environments has reduced the fear of blame and retribution and increased effective communication through the ranks and transformed the speed and value gained from learning. It has done this in part because every AAR creates a safe environment for learning due to the actions of the AAR Conductor and the organisational commitment to using AAR. Professor Amy Edmondson has spent over 20 years researching the components of effective 'work groups' and summarises what increases team performance as "psychological safety". It can be defined as "being able to show and employ one's self without fear of negative consequences of self-image, status or career".3 High levels of psychological safety in clinical teams have numerous benefits for safe and effective care.4 My experience has taught me that with repeated and regular use of AAR, the psychological safety experienced during them, shapes and influences behaviour positively outside of them. Another reason AAR works to improve patient safety is the quality of the learning and changes in behaviour coming out of them. Here the research is also very clear. A meta-analysis of research into AARs5 demonstrated that the learning coming out of AARs can improve team and individual performance as much as 25% when compared to control groups. This analysis of research in a wide variety of settings showed that participants learnt so effectively through the AARs, that they were able to perform and deliver up to 25% more effectively afterwards. This is because the participants in the AAR are fully involved in their own learning so instead of being talked at, they are being asked to make sense of the shared picture of the event that has been generated in the AAR. The responsibility for learning and change in an AAR, therefore, rests with the participants and is directly relevant to them. In a clinical setting this means that improvements in safety and behaviour can start the minute the AAR ends. Contrast this with an investigation, where the learning is owned by the investigator and the organisation that employs him or her, and the responsibility for change rests far away from those involved in the action. The quality of the shared mental model that is created in the best AARs directly supports learning about patient safety matters as the individual participants access other people’s experiences to gain an overview of an issue. The skilled facilitation by the AAR Conductors is a vital part of this, as once a safe learning environment is established, cognitive biases and prejudices are reduced and clearer thinking is possible. Patient safety learning is also greatly enhanced through AAR because of both its 'learn as you do' approach and the fit with effective adult learning theory models. AARs do not require clinical staff to leave the ward for days at a time for traditional teaching about patient safety. Instead AAR practice makes it possible for learning about patient safety to become an everyday habit and, therefore, more effective. Since the AAR process allows individuals to learn for themselves what happened and what got in the way or enhanced safe, effective care, it is mapped onto the individuals own knowledge base and makes a more lasting impact. The last feature of the issues highlighted in the NHS Long Term Plan concerning patient safety was the workforce. My experience of facilitating hundreds of AARs in clinical settings has highlighted its potential to reduce the stress levels of staff as the supportive no-blame environment encourages greater clarity and less personal blame. Lower stress levels will have an indirect but valuable effect on staffing levels as sickness absence may be reduced and retention boosted. This is just a summary of some of the features of the AAR approach which I know will enhance patient safety. Other AAR Conductors will have more insights to share, and the academic researchers in the US and Israel universities many more. I would love to discuss AARs further with you, contact me at: judy.walker@its-leadership.co.uk References Pascale RT, Millemann M, Gioja L. Surfing the Edge of Chaos: The Laws of Nature and the New Laws of Business. Three Rivers Press; 2000. Crowe S, Clarke N, Brugha R. ‘You do not cross them’: Hierarchy and emotion in doctors' narratives of power relations in specialist training. Social Science & Medicine 2017; 186: 70–77. Kahn WA. (1990-12-01). Psychological Conditions of Personal Engagement and Disengagement at Work". Academy of Management Journal 1990; 33(4): 692–24. doi:10.2307/256287. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines : Team Learning and New Technology Implementation in Hospitals. Harvard University Administrative Science Quarterly 2001; 46: 685–716. Tannenbaum SI, Cerasoli CP; the Group for Organizational Effectiveness. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors 2013; 55(No. 1): 231–245.