Department of Health Systems Administration, Georgetown University School of Nursing & Health Studies, Washington, District of Columbia 20057, USA.
J Public Health Manag Pract. 2013 Sep-Oct;19(5):420-7. doi: 10.1097/PHH.0b013e3182751d57.
To analyze key variations in the after action report/improvement plan (AAR/IP) process used by state and local health departments following the 2009 H1N1 pandemic and identify ideas for improving that process.
Workshop participants discussed their AAR findings and the methods used to prepare their reports and implications for improving the AAR/IP process in future events.
Workshop participants included state and local health department personnel who had submitted AAR/IPs to the Centers for Disease Control and Prevention (CDC) for review.
Workshop participants were asked to consider the question: On the basis of what you heard in this workshop, what would you do differently if you could redo your 2009 H1N1 AAR/IP?
Workshop discussions revealed wide differences in the participants' understanding of the intended uses and users of the AAR/IPs, their scope, timing, and format, and the use of external consultants in their preparation, and on the strengths and weaknesses of various approaches. The AAR/IPs also varied in the extent to which they sought to identify root causes and the methods they used to do so.
The AAR/IPs can be useful for both accountability and quality improvement, but these objectives require different foci and methodological approaches. Notably, the AAR/IPs can also be used as an opportunity to hold health departments accountable for conducting root cause analyses and making the improvements that follow from them. Federal agencies requiring the AAR/IPs should clarify the purpose and issues of scope and timing; develop training materials and exemplary cases of effective AAR/IPs, particularly of root cause analysis applied to public health emergency preparedness, professional guidelines, and standards for consultants; and consider developing a peer model for preparing AAR/IPs.
分析州和地方卫生部门在 2009 年 H1N1 大流行后使用的事后报告/改进计划（AAR/IP）流程中的关键变化，并确定改进该流程的思路。
工作坊参与者讨论了他们的 AAR 发现以及用于编写报告的方法，以及对未来事件中改进 AAR/IP 流程的影响。
工作坊参与者包括向疾病控制与预防中心（CDC）提交 AAR/IP 以供审查的州和地方卫生部门人员。
要求工作坊参与者考虑以下问题：基于您在本次研讨会中听到的内容，如果您可以重新编写 2009 年 H1N1 的 AAR/IP，您会有哪些不同的做法？
工作坊讨论揭示了参与者对 AAR/IP 的预期用途和使用者、其范围、时间安排和格式、以及在编写过程中使用外部顾问的理解，以及各种方法的优缺点存在广泛差异。AAR/IP 在确定根本原因的程度以及他们使用的方法上也存在差异。
AAR/IP 可用于问责制和质量改进，但这些目标需要不同的重点和方法方法。值得注意的是，AAR/IP 也可以作为一个机会，要求卫生部门负责进行根本原因分析并采取随之而来的改进措施。需要 AAR/IP 的联邦机构应澄清目的和范围及时间安排问题；制定培训材料和有效的 AAR/IP 示例，特别是将根本原因分析应用于公共卫生应急准备、专业准则和顾问标准的示例；并考虑为编写 AAR/IP 制定同行模式。
