Trust Board Clinical Presentation Maternal & Neonatal Health Safety Collaborative – Feb 2018 Michelle Cudjoe – Head of Midwifery and DCN Karen Jermy – Lead Clinician O&G Bill Kilvington – AD WACH Lizzie Hamilton – Maternity Matron Ingrid Marsden – Neonatal Matron Denise Newman – Deputy HOM & Governance Lead An Associated University Hospital of Brighton and Sussex Medical School
The National Agenda • Better Births: 2016 • Maternity Transformation Programme - Aims to provide structure to help achieve this vision • There are 9 national programme work streams which are supporting local implementation of Better Births. • National Maternal & Neonatal Health Safety Collaborative - Workstream 2: promoting good practice for safer care - Launched Feb 2017 - 3 year programme: all maternity services allocated to 1 of 3 waves
The collaborative • Gives Trusts access to QI training & expertise • Enables collaborative working to improve clinical practice and reduce unwanted variation • Will help us contribute to the national ambition to reduce maternal deaths & rates of stillbirths, neonatal deaths & brain injuries that occur during or soon after birth by 20% by 2020 and 50% by 2030
Title Creation of a learning system that will ensure a reproducible, adaptable method of ensuring that all members of the multidisciplinary team have an opportunity to learn from all clinical events highlighted through the risk process Aim Statement 100% of staff working within the department (across all disciplines) will have access to learning and actions from certain cases reviewed by the risk team, by March 2018 Background To improve dissemination of learning from both good practice and adverse outcomes, within the division. This will include historical claims/litigation events, CTG cases, neonatal deaths and stillbirths, to ensure learning has been embedded in ongoing practice. A significant amount of hard work is undertaken by the core risk team, including clinical case reviews, root cause analysis, identifying trends and disseminating information. We want to ensure that the learning and actions are disseminated to the whole team in a timely manner.
Title Develop and implement an Induction of Labour pathway that provides assurance that IOL is undertaken for appropriate indications and is effective Aim Statement To reduce inappropriate IOL at 37-40 weeks gestation, by 50% by Sept 2018 Background The IOL rate has been increasing over the last 18 months. We need to provide assurance (to ourselves and the Trust) that all IOL (at whatever gestation) have an appropriate clinical indication, but especially at 37-40 weeks as it will be likely that this group have an increased rate of intervention and NNU admission. It is likely that there are an increased number of IOL attributable to appropriate clinical indications (gap/grow, reduced FM), but this means the service is less able to accommodate the more flexible indications for IOL (eg: SPD). This improvement project will help us identify capacity/staffing/effectiveness issues to plan a safe service if increased capacity is justified. Reduction in variability of clinicians’ practice.
Title To identify the avoidable causes of admissions to the NNU between 37 and 40 weeks gestation Aim Statement To reduce avoidable admissions between 37-40 weeks gestation to the NNU by 50% by March 2018 Background Our term admission rate is currently 6.6% As a multidisciplinary team we need to understand why babies at term are unexpectedly admitted to NNU. We need to assess each case to see if a different intervention at a different time would have had a different outcome. Once we understand the reasons for admission on a detailed level we can look at different interventions to reduce admissions
Title To identify how best to work with mothers and families to help inform clinical case reviews and root cause analysis as part of the investigation process into adverse outcomes. Aim Statement For 100% of families to be offered the opportunity to be involved in the risk process related to the investigation of stillbirths, early neonatal deaths and other (moderate) clinical incidents undergoing RCA, by April 2018 Background As a team we want to understand how best to involve mothers/families in clinical incident reviews of SI/adverse outcomes and moderate incidents, incorporating their views and experiences. This is in line with MBBRACE suggested actions. Duty of Candour: has been introduced in the Trust, and we are compliant within maternity, but certainly within obstetrics, the level of user input into development of the template letter is unknown. Is it in a format that parents want/when do they want it etc. We want to understand how parents want to be involved, in what forum, their level of involvement. We also want to be able to feed back to the multidisciplinary team, the outputs from the parents, for example through patient stories (this links with Human Dimensions improvement project too) etc
SASH Mat/Neo Dashboard HOW TO READ A RUN CHART This is a (modified) Run Chart - it is a graphical way of showing a Something clearly changed process over time in a way that that affected the 'run rate'at can show if something has this point. This happens to be Rules of a run chart changed, or if a conscious the induction chart and at this All inductions (Target 27%) Induction target 1. 20+ data points to be meaningful intervention in a process has had point Gap/Grow was 2. Less than seven consectuve points going up introduced. There is still normal 45.0% any effect. variation, but mostly above the or down is NOT a trend (yet!) long-term average 3. Five consecutive data points above or below 40.0% The red line is the mean is a run and might show effect of a the average over change in process 35.0% time 30.0% 25.0% The green line is a target you The data line is showing wish to achieve - in this case 'normal variation'. It goes up 20.0% and down each month, but the maximum, so rate should there is no particular pattern be below the line 15.0% 10.0%
Developing our Dashboard Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” H. James Harrington
Sharing Learning and Experience • KSS Patient Safety Collaborative Communities of Practice - SASH presented at the 1 st meeting 8 th February • SASH presenting at the NHSI National Learning Set for Wave 2 Trusts - 1 st March
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