Maternal & Neonatal Health Safety Collaborative Feb 2018 - - PowerPoint PPT Presentation
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
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
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
the mean is a run and might show effect of a change in process
HOW TO READ A RUN CHART
Rules of a run chart
10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%
All inductions (Target 27%) Induction target The red line is the average over time
This is a (modified) Run Chart - it is a graphical way of showing a process over time in a way that can show if something has changed, or if a conscious intervention in a process has had any effect.
The green line is a target you wish to achieve - in this case the maximum, so rate should be below the line The data line is showing 'normal variation'. It goes up and down each month, but there is no particular pattern Something clearly changed that affected the 'run rate'at this point. This happens to be the induction chart and at this point Gap/Grow was
variation, but mostly above the long-term average