By Ashleigh Townley, Joanna Wincentak and Shauna Kingsnorth

The COVID-19 pandemic has brought a whirlwind of change to the Canadian healthcare context and daily practice of healthcare staff. Rapid shifts to telehealth and virtual care, routine adoption of enhanced personal protective equipment (PPE), mandatory symptom screening for staff and patients, as well as increased work-from-home arrangements are but a few examples.

For many healthcare workers, the speed of these changes has left little time to consider broader impacts beyond immediate goals, to them as individuals and as teams in their workplace setting².

Protecting time for teams to reflect and learn from their collective COVID experiences can offer a beneficial pause; generate discussions that are helpful to staff, organizations and systems; provide an opportunity to catalogue events during periods of rapid decision-making; and make recommendations for changes to current practices and future reactions to healthcare crises.

One tool to help structure this reflective process is called an After Action Review (AAR). Adopted by the World Health Organization (WHO) for healthcare crises, AARs “… are structured, qualitative reviews of the actions taken during the response to identify best practices, gaps and lessons learned”³ and are “…not intended to assess individual performances or competences, but rather to identify functional challenges that must be addressed, and best practices to be maintained”⁴.

At Holland Bloorview Kids Rehabilitation Hospital, the Knowledge Translation team, Evidence to Care, is using the AAR format to support clinical, management and senior leadership teams to understand rapid adoption of virtual care, organizational communication, and leadership’s decision-making process during COVID-19. Externally, Evidence to Care has supported the Toronto Academic Health Sciences Network (TAHSN) Learner Engagement Advisory Group to understand the removal and reinstatement of students to hospital learning environments during the pandemic.

There are a range of ways to facilitate an AAR, from multi-day organizational retreats, to short interviews with select individuals⁴. An AAR consists of key questions that should be tailored to context⁵. Here are some examples:

• What was expected to happen?
  • What was expected to happen with learners in TAHSN hospitals in the event we experienced a pandemic?
• What actually occurred?
  • What actually occurred with senior management decision-making and communication between March – May 2020 as the hospital reacted to the COVID-19 pandemic?
• What went well and why?
  • From March – May 2020, what went well with virtual care at the hospital and why?
• What can be improved and how?
  • How will your learnings about communication systems, structures, tools, and strategies impact how the team does things in the future? What are specific recommendations?

In Evidence to Care’s experience, to generate the most useful results for pandemic learnings, AARs should be conducted with:

• A defined group of staff or volunteers that work together or have similar roles (e.g. operations managers, a single clinical unit, or a committee dedicated to pandemic efforts). Consider power dynamics in groups that are participating. Will the presence of management change the answers from other group members? Consider holding a separate AAR with management and leadership.
• A topic that focuses on one area of the group’s pandemic response over a specific period of time. For example, an AAR could be conducted with an organization’s physiotherapists to understand their transition to virtual care delivery during the first six months of the pandemic (a period of time with rapid change).
• A minimum of one, two-hour meeting, with the potential for a second follow-up meeting to review, clarify and confirm AAR results.
• Facilitators from outside of the group participating in the AAR. At least two facilitators are recommended, one to lead the group and one to take notes and observe group dynamics. If a team is large, using smaller subgroups is helpful. We recommend having one facilitator per subgroup.
• A lens to interactivity. If in-person group activities are prohibited or pose other challenges (i.e. masks hinder hearing), consider a video call platform. For example, Zoom has many features like breakout groups, polling and chat functions, that make running an AAR more interactive than can be achieved in-person during the pandemic.
• An actionable report that catalogues the synthesized themes and recommendations. Recommendations should have accountability to implement changes attached to them, and be reviewed and updated on a predetermined schedule (i.e. biennially)

When the AAR is completed, the results should be reviewed with the contributing group. If possible, provide support to groups to prioritize and select recommendations to implement.

AARs are a relatively easy to use, resource-conscious, quick and powerful reflective tool that can enable teams and organizations to capture key learnings during this transformative period of health care practice.

Ashleigh Townley, is the knowledge translation specialist; Joanna Wincentak, the knowledge broker; and Shauna Kingsnorth is manager, Evidence to Care at Holland Bloorview Kids Rehabilitation Hospital.