After Action Reviews Improve Systems, Strengthen Teams

by Domonique Davis, Communications & Digital Strategy Manager

May 25, 2023

Sandra Widland, MPH
Sandra Widland, MPH
NICHQ Project Director

An After Action Review (AAR) is a structural process of reflecting on a performance. Whether you're reflecting on large projects such as webinars or big meetings or conferences, or smaller projects and internal processes, conducting an AAR is a great way to improve your systems and strengthen your teams.

During an AAR teams come together to discuss four main questions in a facilitated fashion. The questions are: What did we intend to happen? What actually happened? What should we sustain about what happened, and what we can improve about what happened? Through those four questions, recommendations for improved processes and systems can be discussed and identified.

The National Institute for Children's Health Quality (NICHQ) has incorporated AARs as a quality improvement tool for the past four years. Read a conversation with NICHQ Project Director Sandra Widland, MPH,  and Associate Project Director Eliza Williamson about the ways NICHQ utilizes AARs in various projects and its benefits to healthcare professionals and others interested in improving systems.

Eliza Williamson, NICHQ Associate Project Director
Eliza Williamson
NICHQ Associate Project Director

Can you share a little bit about what the After Action Review process helps teams achieve?

Sandra: It's just those four questions, but a lot comes from that. if you think about what we intended to happen versus what actually happened, rarely do those two things perfectly align. In any sort of project work like the work we do, there are always changes to the system and changes to the circumstance. Maybe a new staff person comes on or another staff person leaves, these things happen, and it's important to reflect on what happened and why, and what you can learn from this. This whole thing is really about being curious about the systems that exist within your organization and learning from what you've experienced.  

When I think about what makes an AAR special, to me what really stands out is that it's facilitated by somebody outside your team. Typically, they're about an hour long. They can be longer if you want them to, but it's facilitated by somebody else so that your whole team has an opportunity to fully participate. The second thing is that you always start off, before asking those four questions, by establishing ground rules. The purpose of the rules is to provide psychological safety so that you're all operating under the same conditions and can maintain a certain level of trust.  For example, when you think about ground rules you can think about whatever the team thinks needs to exist in order to have authentic conversations. It could be that people only speak for themselves rather than for the group or that you commit not to interrupt each other. You commit to really making sure that all voices are heard in the meeting. And to that end, when you think about any team, there are always some participants who are more vocal and speak more during your interactions. The After Action Review is really designed so you hear from everybody, which is so important if you want to really reflect on what happened. It's an amazing tool to really identify intended outcomes versus the actual outcomes and what you want to sustain and what you want to improve. 

How did we start using After Action Reviews at NICHQ and how has that process changed or grown over time? 

Sandra: A colleague on a project I was working on previously brought the idea of After Action Reviews to NICHQ. She used it at a previous workplace and had a great experience with it. It was actually a tool that was developed by the army for combat missions. We were working on a final report, and that project was coming to a close so she suggested we might learn quite a bit from conducting an After Action Review. We found somebody to facilitate the conversation and went through the review and everyone thought this is incredible and asked “Why aren't we doing this on other projects?” We trained a few facilitators at NICHQ, and then we started asking projects to consider doing a review of something that they felt was important to reflect on. We just started small because we're an improvement organization and we always start small and test things out with one or two projects and learn from that before refining the test. We started off by looking at projects that were closing and then began testing After Action Reviews with projects that were doing something different, like hosting a big webinar or implementing a new system, and began to just have incredible learnings from doing this. We eventually brought it to the leadership of our organization and said we're really seeing a lot of learning across projects, and some projects are experiencing similar situations – both in positive aspects and areas that need improvement. How can we elevate this and really implement this across the organization to make this a new system at NICHQ that we do with all our projects? Now, we're really looking to sustain those efforts, but it just started off small with one project and grew from there.

Domonique: After Action Reviews often allow you to tease out something that might seem like a niche issue with your project team or the folks who are involved. And then when the organization is able to review on a larger scale, you see some of that overlap, some of it is overlap in our organization, but we can even begin seeing industry similarities with successes and challenges.

Sandra: Our organization can really point to some systematic changes that were made because of these After Action Reviews. For example, we found that many projects reported that they needed a little more onboarding time before the project started to get to build a relationship with the funder of the project or to build relationships with the participants of the project. Maybe they needed to learn a little bit – if the project was specifically focused on quality improvement, they might need to do sort of an assessment to gauge the level of knowledge about quality improvement at their institution. And so that's something where now when we apply for project funding, we try to build that onboarding time in, and that's something that specifically came out of these After Action Reviews. 

Can you provide an example of an After Action Review that went really well and what were some of the factors that contributed to its success? 

Eliza: On the Florida project, the first After Action Review we conducted was after one of our big main events, which we call a learning session. Then we started to conduct them annually, and often much of what comes out of the After Action Review informs our annual report or our strategic plan for the next year. So, we're always very mindful to set a clear goal for our time together, which allows it to be a really successful conversation. Still using those four key questions, but there's so much going on in these projects, just being very aware of what it is that we specifically want to talk about has been really helpful. For us, the After Action Reviews have gone well when we stick to our ground rules. The facilitator is key. Having someone who's going to keep us on topic and keep us moving and make sure that everyone's voice is heard makes a big difference. Also, allowing everyone to give input has been really important to us. In our project, the After Action Reviews have allowed us to create more psychological safety within our team. We've worked together for so long that it's hard to tell if it’s the chicken or the egg, but I do think that for teams starting out, an After Action Review will definitely help bring more psychological safety. After Action Reviews can be useful in creating organizational change because they help bring the perspective of looking at the whole system rather than the individual. If there was a mistake made or something went awry, an After Action Review allows you to look into what's behind that and look into the system behind that and have a safe space to have those conversations. 

Sandra: It's a great way to practice focusing on systems learning and to refrain from this idea of assigning blame. This way you can keep your team feeling supported and intact while getting to the root of what happened and how it can be improved.

You mentioned that After Action Reviews can help facilitate difficult conversations. Do you have an example of a challenging After Action Review and lessons learned from that?

Eliza: The After Action Review creates a safe space to have hard conversations and have them in a constructive way where people know that they're coming into that space and they’re not going to be judged, they're not going to be blamed. I can think of one specific After Action Review where we were at a key moment between some big changes on the project and it allowed us to put everything on the table and talk things through, look at our system, and then make concrete recommendations for ourselves – even down to some operational changes that we wanted to make. Most importantly, we came out able to synthesize our thoughts together and were able to share some of those themes and recommendations with leadership so that we could get support in making some needed changes to the structure of the project. A lesson learned in all of this is to do After Action Reviews frequently and not wait and shy away from the conversation, just dive in together. 

Sandra: Something we do see happen with After Action Reviews is that some voices are elevated in a project more than others, and this may be the norm for that team. So, it does fall on the facilitator to say, “There are some folks that we have not had an opportunity to hear from yet, let's really give them the floor now to share.” And then it is up to that person, if they then feel comfortable with good ground rules and good facilitation, to share. As a backup, if that doesn't happen, we do send out a Reflections Worksheet the week before so that participants can bullet point how they feel or what they think about each of the four guiding questions for the After Action Review. It helps you get organized before this meeting so you get to say what it is that you want to say. It's up to you if you want to turn it in to the facilitator to add to the notes. You don't have to, but if we feel like someone just doesn't seem comfortable for whatever reason, we take that measure.

Why would you encourage healthcare professionals and others interested in improving systems to begin implementing After Action Reviews?

Sandra: Healthcare is a busy place to be right now. There's high turnover, there's burnout, and it's just more fast-paced probably than ever because of those two factors, so doing something like an After Action Review might sound too time consuming. However, I would argue that it will save you so much time and maybe even bring a little added joy to your work. It saves you  time in the sense that, it’s a one-hour meeting, but you can use that time to help pull the outline together for larger reports so it actually saves a tremendous amount of time because it's a facilitated conversation and everyone gets to speak. We get to make sure everyone's voice is heard, and it helps identify problems within the system and gives you opportunities to improve rather than letting those things snowball. It's also nice to hear from your colleagues and learn their perspectives, especially the ones you don't get to hear from as much.  As our colleague at NICHQ always says, it's important to look back in order to leap forward. And when you look back more times than not, maybe every time, there will be something to celebrate. There will be something within that reflection that is cause for celebration. And we don't celebrate enough. We need to celebrate more. We all work really hard, and we're all working to improve health outcomes. That is so important. And when you do have a win, you've just got to celebrate it. And this helps to really call out those wins. 

Eliza: The only thing that I could add is just that we're really big fans of this tool here at NICHQ. We've described a lot of the process and benefits, but I would say at the core, it is a pretty simple tool. And if you do it well, you'll be able to do it, it can make a really big impact. And we all believe in the process. So don't be afraid just to jump in and try it out.