Clinical event debriefing has become a recognised quality improvement initiative in healthcare. This form of debriefing is a facilitated reflection on the actions and events of the case. They are often performed closely following a critical event and enable the team involved to identify any learnings and system issues. Team members are encouraged to explore aspects of care in a safe environment, share what went well, and aspects that did not go as planned and how care could be improved in future. Successes and learnings can also be shared with the wider department. Clinical event reviews are not emotional debriefs.

At Sydney Children’s Hospital (SCH) the Critical Care Simulation Team implemented After Critical Event (ACE) reviews in 2020 in SCH Emergency Department. The review process is evidenced based and an integral part of our Quality and Safety Program. Since 2020, ED has conducted over 100 ACE reviews. Many of these identified system issues that have been addressed to improve patient care.

To build sustainability of these reviews at SCH, we rolled out an ACE Facilitator Workshop. The workshop is a 3-hour course aimed at developing the required skills to conduct an ACE review and promote psychological safety during an ACE review. Candidates are orientated to the ACE Facilitator resources and given the opportunity to participate in a simulated ACE review to build familiarity with the process and resources.

Since 2022 the program has expanded outside the ED, with 92 staff trained as ACE facilitators. Resources are now easily available on the intranet to support implementation.
This presentation will outline the ACE review processes and elements of the ACE Facilitator workshop at SCH. The resources created for an ACE facilitator will be presented and demonstrate how they can bridge the gap and support organisational change.