 It is my great pleasure to introduce Vicky Penwell and her presentation today here at the International Day of the Midwife. So Vicky Penwell is a licensed midwife and the founder and executive director of Mercy in Action. She's attended birth since 1981 beginning in Alaska and is responsible for the safe delivery of more than 15,500 babies in the Philippines since 1991. This is all at no cost to the parents and with outcomes that are four times better than the Philippines national average, even though the birthing population is mixed risk. This has been accomplished by midwife lead care in community birthing centers serving the poor that stresses low intervention in normal birth and high intervention in birth emergencies and constant after action review just to improve in all aspects of midwifery practice. Vicky also serves as executive director of the Mercy in Action College of Midwifery, a four year bachelor of science midwifery college accredited in the USA. In recent years, Vicky created a post graduate diploma in international midwifery and maternal and child health under the college that has scholars in dozens of countries on four different continents. Vicky has a master's degree in midwifery from the US and another master's degree in intercultural studies from the Philippines. She lives with her husband of 41 years in Lungapul Philippines. She travels to teach midwives around the world and still occasionally attends births and helps with disaster response and outreach when the need arises. So wow what a bio that is so nice to have you here with us Vicky. I am going to hand over the presenter rights for you. Thank you very much. Okay. Thank you red. Well welcome to everybody that is here. I have so many fond memories over the years of being up in the middle of the night at a long labor on May 5th and going to the computer and watching sessions in the middle of the night. And then you know of course during the day to when it's normal hours but it's great to be with you here wherever whatever time zone you're listening from. We are often asked the secret to our success of having delivered such high numbers of babies now for very, very people living in poverty and oftentimes high risk situations and yet having such great statistics. There's probably many things I could say about that but I want to say living in a culture of humility as midwives and a culture of constantly wanting to be lifelong learners and always get better has been one of our secrets. So today I'm going to talk about the after action review. I do talk about this a lot as an educator as well as a practicing clinical midwife, because it works everywhere. But if you're here and you are working as a midwife or in maternity care and you're not you don't have a student right now or you're not a student that's okay too there's something for everybody here today. So I want to start out by just saying that right after in 2001 after 911 I first was aware that the that the military used something called an after action review and I learned about this I was instantly fascinated. It is used to have a professional discussion of an event and it's focused on performance standards. It helps everybody that was involved to discover for themselves what happened. They look at what are their strengths was their weaknesses. How did they function together as a unit. It gives insight into each individual and also their leader and their and their whole the whole situation. And when I first heard about that I thought well now that's really interesting because I would love to adapt that for midwifery because there's certainly similarities. I think we also are working in a profession where things can change very quickly and become life life threatening life defining and we have to make fast decisions. We have to have good training that those are based on our equipment has to work for us our environment has to work and we have to work together as a team. So that kind of was what sparked my interest all that time ago almost 20 years ago now. I have found out since in all my work with disaster management that that many disaster organizations are using this now FEMA is using it in the United States they used using it after disasters all over the world. And we are using it we have been for almost 20 years now using it mercy and action in our clinics and also with training students. And we have taught it to midwives all over the world because of our continuing education courses. Before I go any further I just want to give you this one quote because it'll help you understand how this all ties together one team member reported without an after action review you keep learning your lessons again the hard way. And that's what we don't want to do. So after action review and how we use it with students. I want to say before we go any farther really talking about this guide. Your students should look like this picture. They should be happy like this I think in order for adult learning to really occur. The student have to have to feel safe. They have to feel supported. They have to feel valued. So after action review is one way that we build an entire culture into our our clinical practice so that students do feel safe supported valued and hopefully happy to be there. So after action review in practice. What is after action review in practice well we sit down or we just step aside for a minute after any clinical experience. So we usually we think about this around birth which it is but we also could do it after any clinical practice as will show. And we ask these three simple questions and this is at the core of an after action review. We ask what did we do right or another way that we could word that was what went well and why did it go well. We also ask ourselves a hard question that not everybody is comfortable asking but we want everyone to get comfortable with this question. What did we do wrong where it was a mistake made what went wrong and why did that happen what did we fail to build into our entire system before that happened. So that's a very important question. This is one that can bring people to tears but once they get used to the culture of everybody feeling safe then it's a very very powerful question. And we ask what could we do better. So another way to word that would what can be improved and how because we're constantly in this frame of mind of wanting to get better and do better. At what we do and not make the same mistakes again or we also look at what could we improve upon what we were doing right. So this is a guide for midwives working alone or midwives working with students. The quality learning is always happening and what we're doing as a team and I want to really stress this as a team not as an individual necessarily unless you work all alone. If you do I would suggest you do after action review with your birth assistant or the nurse that assists you or a doula. But the idea is that the team is continually assessing their performance and identify and learn from success and failure. So the after action review is simply a tool but it's a very powerful tool to help you do that. And conducting one at the end of every birth it doesn't matter if you've been to thousands of births if you're the most experienced person on the planet. If you're a student that's about to graduate it or you're just starting at any point it's helpful to learn from our clinical experiences. And sharing the results of the after action review helps your entire team learn which strategies are successful and how do we avoid the pitfalls. So we're going to ask a lot of questions when we're working with students so beyond just those three big ones. What did we do right what did we do wrong what could we do better next time. We're also asking our students to really critical think through what did you expect to happen at that birth versus what actually happened. That's a very powerful way to think sometimes people just assume they kind of you know look at at a at a particular history or situation set of risk factors and think oh I can tell which direction this first going to going to go but what actually happened how are you surprised. What did you learn for the first time and that's such a fun question and I remember being a midwife student myself way back more than 40 years ago and and I had a journal that I just write down every new thing I learned every day. It's a really great way to learn. We're also asking students to tell us what was unusual or unique about this case. What do you need to go research more based on what you just saw. So the after action review will hopefully lead students to get out their textbooks get on the Internet and keep learning. The features of an after action review are an honest and open professional discussion participation by everyone on the team. So the students are very much a part of this anyone that attends the birth or clinical experience. The focus is on the event. So what happened at the event and we're focusing on ways to sustain what was done well and ways to develop recommendations for overcoming any problems or obstacles. So when we look at after action reviewing something don't just think of the birth we might do it after a prenatal exam. So the student and the senior midwife preceptor is in a clinical exam and after then they're alone again they might just sit down and talk about what happened there. Why did we schedule visits the way we do why do we recheck due dates. What questions did we ask we might say what we did wrong was what question did we forget to ask. What could we do better next time maybe we decide we should run more labs maybe we think you know what we should have done was check her reflexes. So we're always thinking what could we have missed because it's not too late. The after action review should always happen very very quickly after the event so that if we find something we could do better next time. It may be even something we're going to call back after action review is for all preceptor and student teams. Who want to maximize their learning and regardless of the outcome of a birth or a clinical situation. There's always success to document and there's always lessons to learn and everybody gets a voice that's a very important feature of the after action review. So sometimes students do an after action review with other students or primary midwives. All experienced midwives in the room will do an after action review with just themselves. But it's really most powerful if you have a combination of all the people that were at the birth and all the different roles and that it's a joint review with everyone. So at a birth for instance once the baby and mother are stable and we're at that point where the baby has already breastfed and all the vitals are normal. Our son is born and bleeding is minimal. We oftentimes leave families alone to bond and we'll just step into the next room and do an after action review. The after action review should be done in private. This is not where you talk about what happened at the birth with parents or family members. So if you don't have a private place then you'd have to wait till later. But the idea at a birth is that it's conducted very shortly after so that we can gather the team while everything is fresh in their mind. And almost always we are bubbling over with things that went really well or saying you know what I could have done better. I know I did this and it wasn't just quite right and we could do it better. All that gets lost within a few days time. And this doesn't have to take real long as we'll talk about. The postpartum exam gives us all kinds of things to after action review. Are all the vitals normal? We now have two patients as it were. What does the mother need? What's going on with her healing physically, emotionally, mentally, everything? Is everybody thriving? What are the family dynamics? So we're really asking students to get deep into thinking even in their counseling if a mother says you know she's struggling with something they can after action review. How did they do? Talking about that, giving appropriate screening for postpartum depression, things like that. So how long does it take to do an after action review? It's usually not going to be more than about 20 minutes for a birth. And if it's a prenatal or postpartum it might only take about five minutes. So it doesn't have to be long but the value is doing it right after the event happens to avert any problems. We after action newborn care. Does the newborn have any problems? Is bonding happening? What happened at the birth that might have impacted the baby's health? Like was there a transport? Was the baby born where we expected it to be born or somewhere else? And then we have emergencies. So what we want after action review really well anytime we had an emergency a transporter referral and we want to look did we make good decisions based on the criteria that already existed for us? Were proper protocols followed? Who's going to follow up on this situation now if we're no longer in the site maybe where we're used to working? And when we have a bad outcome, so if we have a traumatic event or a frightening emergency or maybe a less than ideal home to hospital transfer then we want to change our timeframe instead of just taking 15 or 20 minutes we're going to first of all we're not going to be able to gather the team probably right after because teams get really scattered when there's an emergency. Somebody may have stayed home with the mother because she hasn't delivered the placenta. Somebody went with the baby. Everybody's scattered or maybe you need to stay longer at the birth because there's problems and so other people on the team go home. So the thing is to gather everybody again and this is the hardest one to do but it's the most important after action review is when things really didn't work out the way you hoped and there was some sort of emergency or even a death. So what we suggest is that you arrange the next day. No more than 48 hours ideally 24 hours gather the team and then spend the 15 or 20 minutes per team member to let them share. So it's not just get it over in 15 minutes it's everybody needs to talk about what happened they need to talk about how afraid they were they need to probably cry over anything they did wrong that they feel like could have made a difference. I was very clumsy getting the oxygen open I should have had it set up ahead of time. You know things like that that are really going to be emotional for people dealing with the fact that they may not have been as prepared and the whole idea is not to make anyone feel bad but to say next time this happens. Next time we have a baby born that's not breathing we are going to be so ready we are not going to let that happen again. That's just one example. So you can after action review everything. So when you get used to thinking like this it just opens up your world and you'll find yourself after action reviewing everything not even just birth but like you know Christmas dinner or something like well as to talk about what could we do better. But we always want to talk about the unexpected the what we learned now who is going to lead these discussions is often going to be the senior midwife or if it's a student and preceptor the preceptor will lead the group. And just remember you're always coming back to those three questions what did we do right what did we do wrong what could we do better next time or how could we improve. And so what you break that down into is what what unexpected happened but instead of just saying oh well that was a one off you're like going to say you know what that was very rare. But if it ever happens again we'll be ready next time. And we want to ask these really important questions about the mother baby what guided us what did we learn from them maybe what did we fail to listen to the clues. So the goal of the after action review is for one it just naturally makes learning very dynamic. Everyone gets a voice even the youngest student everyone shares what they learned what they thought could be done better what was emotionally charged. You're always asking people what did you find scary what was fun about that. So the goal is to guide and improve the work of future birth teams. We're not grading success or failure there's not a grade. But it's just acknowledgement that we're all learning there's always weaknesses to improve and there's always strengths to sustain. And participants should share their honest observations about what really happened. Now if you haven't worked to really build a birth practice that feels safe for people to honestly share. And you need to work on that first but in Mercy in Action we're really passionate about that piece that we're all going to be humble we're all going to be learners we're all wanting to improve. So at first sometimes the newer student or the newly hired midwife will feel shy but we encourage them and and pretty soon they're able to find their voice to say what actually happened without assigning any blame. And set an atmosphere of openness so one of the things we do before we start every actual review is just introduce the ground rules the expectations of honesty openness compassion for each other. Okay again just a little bit of a review after actual review is an honest professional discussion so everyone participates there's no hierarchy. It identifies ways to sustain what was done well now I want to pause on this for just a minute because sometimes we get so hung up on what we did wrong. We don't remember that oftentimes we do things right for a while, like when a new piece of evidence based knowledge comes out or something just really great. And we do it for a while and then we can slip back into the old ways we can slip back into being products of our own education and stop doing what really worked. And so after action review not just helps you to not make mistakes but to also sustain what you're doing well and to remember why you why you did that. It obviously identifies ways to improve which we love it helps develop ways to overcome obstacles or problems instead of just complaining about them we're going to come up with an action plan. And that's the point here that there's an action plan at the end for all of this so it's so important that everybody participate everybody be creative and in giving solutions everybody commit to identifying those opportunities we have to do better. So it helps students really focus they they know they're going to be held responsible for after action review so they're in everything remember not just birth every event. So they're going to be really thinking what are the important points what do I have to remember. What do I want to do to explain why I did what I did what are my decisions based on. So we're we're always asking what was expected to occur versus what actually occurred and we're really focusing students in after action review plus the supervision piece is what gives us the quality so in my entire career as a midwife I have always trained students I have never separated the two I feel like it's just so powerful to be a clinical midwife and training the next generation at the same time and what makes it safe what makes it quality. What makes the good outcomes is the the supervision yes but also then always after action reviewing so that the goal is to improve care for the client improve learning for the student. So I think that here we want to always remember that in a healthy student midwife clinical training the relationship should be symbiotic that the midwife and the student are working together for the good of the the family having the baby and that that relationship should be really it should be symbiotic it should be good for everybody. When we're a preceptor and we're pointing out bad points as well as good we want to be really careful to not pass judgment on the student they're learning. We want to always build them up. We want not we don't want to stifle their participation we want them to be heard. They may have to get told they did something wrong with hopefully they're going to say it themselves. The idea is to build a culture where nobody is having to tell someone else they did wrong. They're the ones they go to after action review and are like OK I know I could have done that better and that's just such a healthy way to work together as a team. And remember we've done this in teams that didn't have a student to just midwife to midwife that honesty. So we're also asking what can be improved and how all the time. And in this picture I'm literally putting my hands over the top of a student's hands but that is oftentimes what we're doing figuratively to with after action review. What can be improved and how how can we remove the stumbling blocks to something you don't understand yet. And how can we help every student have a theory and a rationale behind everything they do. Instead of just putting their hands on a belly and kind of mimicking what they saw somebody do they know exactly what they're looking for. They understand the rationale behind everything and this is going to build a lot of confidence in their clinicals as they go along. So we're always asking the students given the information and knowledge we had at the time what could we have done better. And then given the information and knowledge we have now what are we going to do differently in a similar situation in the future. And that's where the older midwife literally holds the hands of the younger. After action review marries theory and practice better than anything I know. Students are always thinking ahead because they're not just passive observers which can really happen with students sometimes where they're just kind of sitting back. Well I wonder what my preceptor is going to do in this situation. I wonder what she'll do with that thing that you know the parent just said. But instead they know they're going to be asked to defend their ideas to ask good questions be ready to meet the next challenge and learning they know they're going to have this event after action review. So they're always going to be trying to go to the root of things and ask why why what did we do what could we do. How could we improve. And it's a really really great way to just always be getting students to keep their brains 100% engaged at all times. After action review demands responsibility of the students to because they know they're going to be asked for attention to detail. They know they have to explain the rationale. We always tell students evidence based practice will change over time it's there's certain things that have changed in the 40 years I've been practicing. We're not saying that everything we do now is always going to be considered the best way to do it. But what we do know is that we have a rationale behind everything we do that there's nothing we're doing just by wrote there's nothing we're doing just because that's the way we learned it in school. We all know we have a responsibility to understand the why and the rationale behind every for a student a new skill for a midwife any clinical practice. And so in this way after action review builds accountability and again I'm focusing on the team. It's fun to see these pictures of a time when we could actually be together side by side which right now we're keeping all our midwives apart so this picture is very bittersweet. We're keeping midwives and teams and we're not letting them be near each other so that we can keep a birth team always available during these times but we I want to just stress with this you know as we're getting to the end here. That accountability is how we close the after action review. So we're always asking ourselves were we following best up to date practice or were we just doing something where we you know reverting to an old way of doing things or were we not up on the best evidence. Sometimes having students keeps us so sharp because they're in the newest edition of the textbooks and and they'll say things and you're always like really show me that and then we're learning from them to it's very great when that kind of learning is happening teacher to student but student to teacher. We're always asking ourselves were we culturally competent in the situation maybe the person was from a different subculture. Were we able to meet their needs and then we're the needs of mother and baby honored that's one of the main questions we're going to ask. We always want to end our after action review on a positive note and that positive note is really our action points. So we're going to assign roles for follow up and whoever's leading the discussion the senior midwife or the preceptor is going to give assignments. And maybe those would look like we noted during an event that we essential piece of equipment was malfunctioning will the the action point will be to assign someone to get it fixed. Or if a student froze during a shoulder dystocia the action point may be to set up an in service training on shoulder dystocia and have the student role play in a simulated case of stuck shoulders using a doll. And that segments into our next point is that we let after action review drive our trainings. We don't just set up a whole year schedule of trainings or continuing education. We are looking at our after action review to lead us and address any deficiencies or weaknesses that we have found in our team. So for instance, excuse me in this picture we're seeing practice of resuscitation again. We might get everything out all the equipment and say all right how are we going to make sure that we're really ready. Whatever situation that we have that comes up in after action review as a point of what we could get better at or what someone did wrong we're going to train on it again. And you want to do that quickly while it's fresh and while people are hungry to be learning. And it's important to note here that one of the strengths I believe of Mercy in Action and of our team over the years is this culture of really embracing humility after action review and gender humility. If you aren't a humble person you won't be able to handle after action review seriously. I know people by their own testimony that have said after action review with us used to drive them to tears but now they love it and it's their favorite thing in the whole world. So all of us can learn to be more humble. Working together here's the great thing about after action review everybody is going to share. You're not going to be the only one saying what you think you did wrong or could do better everyone's going to be doing that so it gives everybody the freedom to admit their mistakes to say please help me work. And improve and it helps us all just commit to being lifelong learners. And I put on the slide in midwifery culture, birth and life because it's it's not just a clinical thing. Once you start thinking life after action review you're going to after action review your cultural encounters you're going to think about areas in your life where you'll think well I could have done that better. How could I do that better next time so it really is something that you'll start processing in every area of your life. So we don't want to be afraid of weaknesses and we want to you know just be be ready to go through life living like this living the results. So synopsis here as we're getting ready to close. After action review is conducted during or immediately after each event. It focuses on intended learning objectives. It focuses on the student the preceptor the birth site and the equipment so all of those pieces all the people at the birth, the actual equipment we use and the birth site itself. After action review homeburst every home is different you're in a different environment so we'll say wow we shouldn't have let her give birth you know in that loft where we had a hard time getting out when we had to transport something like that. Next time we go to a home that has a loft like that we're going to move the mattress downstairs. We after action review our equipment. Okay we got to do better at having better quality whatever in case of emergency. It involves everybody we use open ended questions. Everything is related to specific standards so those would be your practice protocols your. Your regulations or laws where you are and then the best evidence based practice guidelines that we have. And we link performance to subsequent trainings. So we are going to take the after action review and let it guide us in our future decisions on policies to create trainings we want to hold readings to assign and when to allow students to go to the next level of responsibility. So with that I just want to say good luck and have fun implementing this wonderful learning tool into your own midwifery practice, or into your own midwifery training program. I really feel this is a tool for excellence and just as I borrowed it first from the military all those years ago now I want to just tell you to freely borrow our ideas. Adapt them for your situation and I hope this will be a real milestone wherever you are at in your midwifery practice or your midwifery education. We have written about this too and I'd be glad to share some of that but now I just want to give time for questions so I'll turn it back over to red. Wow wiki that was so inspirational thank you so much for sharing what a powerful tool that is and I can see how well it links into you having such amazing outcomes there. I mean I've had the personal pleasure to work with actually quite a few of your students that have come from Mercy in Action and also preceptors and I can see why I like them all so much. So we can hand over to our friends here that are joining us if there's any questions please feel free to add them in the chat. I can see the key that you have a lot of fans here. So Stephanie says, I love how simple the process is yet so profound. She was also saying that she's planning to implement this at the next birth that she's building a brand new team. So that's awesome. Sarah says as a student midwife I'm just learning about the process of reflection and this was very helpful. Thank you. That's one of the things that I wanted to say is I think that you know one of this is such a holistic view into how we learn and how we behave in the world as midwives and with each other. I just think it's such a beautiful gift to be really establishing strong communication skills which is so important in our lives as women and as midwives. Not only that but also to be able to call ourselves out sometimes to have that to get comfortable with being reflective and then also learn to have that compassion for ourselves. I think it's so beautiful and it can be really one of the hardest things as a midwife to not beat ourselves up when we feel like oh man I could have done that a little better. So really learning that as a team and as a student I just think is wow it's so powerful. Colleen says it seems a remedy to avoid to be stuck in routines and protocols. Super true. Natali is asking is there anything you have written that I could read? Ikea I don't know if you want to share something. Yes. So we wrote an article on this for Midwifery Today magazine. I don't remember what issue right now but you could look it up on the Midwifery Today webpage. We have a written article. We have also got I think four continuing education courses up online that people can use for accredited continuing education credit. And I think we talk about After Action Review and almost all of them at one point or another. We're going to put up a course just on this eventually but right now the main place that we've published are what we do with this is in Midwifery Today. Thanks for that and I was also wondering Vicki where is the place that we can direct people to where we can find these three steps and also the questions of the AAR? Oh yes. Okay. So again that's in the article but it's also in some of our continuing education courses which you can find by going to mercyandaction.com. But I will also repeat them. The three main questions are what went well and why or what we did right or what went well and right. Why? The second one is what we did wrong or could be worded what went wrong and why or what went badly and why. And the third one is what could we do better next time or could be worded what can be improved and how. So I'll give you simple, simple questions that give you a lot to talk about. I think one of the other things that's so beautiful about it is that it really gives that opportunity to clear feelings in the moment. I think which is so important right for us Midwives like just being able to stay to not let those moments get stuck to be able to stay open and receptive. And that also helps us to not you know to be able to let our own feelings out and like you said have a good cry in a reflective sort of way can also help us to not perpetuate complications. Exactly. Yeah. Super powerful. Yeah, the longer time spent with complications is important. Could I answer I want to answer one of the questions that I saw up somebody asked if mercy and action provides distance learning and then I noticed someone asked about international students. I wanted to explain a little bit how we have gone through a transformation on that over the years over the decades. And I live in the Philippines so you notice a lot of those slides were from there and then you notice a lot of those slides were from the USA where we have had easy access clinics that were to help everybody and have no barriers to maternity care. What we are now focused on and and this is partly because of a better understanding of cultural competency is to really focus on people getting their primary midwifery education in their own country in their own country of origin. And then we're very much focused on helping people globally, but we're looking at now trying to encourage people to get the primary education in the country they're from if at all possible. So, in the Philippines we're always training but we're training national Philippine citizens to be midwife students there in America we have a college where we have a four year bachelor of science college and it's, it's for Americans, but at the end of that time we also offer an international diploma in midwifery and maternal child health that is for everybody it crosses all boundaries and nations because people could do that as long as they're English speaking they could be from anywhere in the world. So, we're really focusing on the postgraduate part for for being in other countries that are not necessarily your country of origin origin and we're focusing on education within countries for people learning primary their primary start. So hopefully that answered that question. That was great. Thank you, Vicki. Thank you, Scott for putting the link in and I put in mercy and action comms that's correct right. Oh, we have to I'm so sorry. Yes, thank you to my husband for paying attention. The college of midwifery is where all of our education is hold the edu. So, www mercy college of midwifery dot edu is where all our education is found including the continuing education courses the diploma program, all of that the mercy and action comm is really focused on our actual clinics in the Philippines and our anyone that wants to donate toward that toward the running of the birth centers and clinics overseas. Yeah. Super important. Thank you. I had one more question Vicki. I'm just wondering for the students who are joining us, you know, maybe working in all sorts of different settings with all sorts of different preceptors. I'm wondering if you have a little tip for them about how they might be able to sort of nudge their preceptors in this direction. Okay, well I see that Cecilia said we only have two more minutes at this point. It's a lot easier for preceptors to nudge their students into it than vice versa but you can absolutely tell them about it you can give them things to read about it. And if you if you don't have any success just know that as soon as you graduate you can implement it. It's something that people either embrace or they have a hard time with like I said it's not something that's comfortable in all cultures to be so honest and so open and so willing to learn from mistakes or even to acknowledge that we may be doing everything right but we'll lose our edge if we don't keep on remembering it. I'm just wondering why we're doing everything right and really work toward toward always getting better so we had a hard time implementing it when we started because we were so busy and we everybody was so stretched thin and people were like one more thing to do. But as soon as it gets a hold in your in your birth culture then people will never want to let go of it so keep trying and thank you for coming to this talk and I bless you all and hope that you can all share it with the people you work with and that they will embrace it. Thank you so much Vicki for your sharing and your time today and all of the inspiration and love that you've shared with us.