After Action Review and PDSA – 2 sides of the same coin?


In this blog, Stuart Kaill, Programme Development Lead, delves into the Learning Response Toolkits and looks at what guidance is available to NHS workers using the After Action Review (AAR) method as part of the System Safety workstream in Patient Safety Collaborative.

One of the significant changes that health and care workers will experience as a result of the introduction of PSIRF (the Patient Safety Incident Response Framework) is that multiple options will be available to respond to patient safety incidents, helping teams and organisations to be smarter about how they deploy their investigative resource, respond in the most proportionate way to incidents and, crucially, focus efforts on learning and improvement. As part of the plethora of PSIRF documentation, a Learning Response Toolkit is shared in which the standard Patient Safety Incident Investigation (PSII) is complimented by a number of other innovative response methods, including After Action Review (AAR), Swarm Huddles and MDT reviews.

There is much to think about, plan and do for those leading incident responses, not least becoming au fait with the new PSII methodology. Somewhere in the mix, the skills required to undertake these other new learning response methods need to be developed and spread and, to add to the challenge, these methods are brand new to many – there is no training course, handbook or manual.

So last Wednesday, the Patient Safety Collaborative team here at Health Innovation Manchester hosted a lunchtime webinar for Greater Manchester (GM) colleagues, looking particularly at what guidance is available for NHS workers around using the AAR method and what the guidance says.

You are welcome to view the outputs of the webinar in our GM patient safety workspace but for now, I thought I would share one or two reflections about what I find particularly appealing about the AAR method.

4 key questions

AAR is based on 4 key questions that are worked through in a logical order:

  1. What was supposed to happen?
  2. What actually happened?
  3. Why was there a difference? (Positive or negative)
  4. What will we do differently next time?

AAR facilitators will be skilled in posing these questions in nuanced variations but the logic is essentially the same. It perhaps appeals to me personally because I see a parallel with another 4-part model, well-known in the world of quality improvement, PDSA:

  1. PLAN – We predict/ write down what is expected to happen
  2. DO – We record what actually happened – observations and results
  3. STUDY – We compare results to predictions
  4. ACT – We make decisions based on what we learned

PDSA is a simple concept that is nowadays commonplace in the NHS so I wonder if this makes it more likely that staff will be able to grasp AAR easily.

Leave stripes at the door

AAR might be relatively new to the NHS, in patient safety terms at least, but it’s a methodology that has been used in other sectors for years as a method for evaluation, knowledge management and learning from successes and failures. AAR was apparently developed by the US Army as a way of debriefing combat missions and enabling teams to maximise success and minimise failure on future missions. Psychological safety is seen as a key element of a successful AAR and so participants are asked to ‘leave stripes at the door,’ or in other words, hierarchical barriers are removed to ensure that everyone’s observations and contributions are equally valued. It might not be the military but in the NHS, teams can be extremely hierarchical and so having a learning method that is able to ‘flatten the hierarchy,’ temporarily at least, is crucial.

Formal or informal

I anticipate that the majority of organisations adopting AAR as a response method will take a formal approach to utilisation – Appointed facilitators, formally scheduled meeting, standard forms and processes and alignment with policy. However, an added benefit of adopting AAR as a learning response option is that as staff become familiar with the application of the 4 basic questions, AAR could be used informally across a range of other applications, besides patient safety. For example, health and safety, events management, project management or debriefing any event in the workplace.

To summarise, AAR is a simple and versatile concept that should be fairly simple for staff to grasp, especially those staff who are used to applying the PDSA method to learning from doing. It will be exciting to see how health and care teams adopt the technique as part of a suite of learning responses.

Next month, on 28th February, we’ll be having a similar look at Swarm Huddles – another tool in the learning response toolkit. If you are a provider of NHS care in Greater Manchester then please get involved. See our Future NHS workspace for details.

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