Trust Board Clinical Presentation Maternal & Neonatal Health Safety Collaborative Feb 2018

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1 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

2 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 year programme: all maternity services allocated to 1 of 3 waves

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4 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

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6 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.

7 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 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 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.

8 Title To identify the avoidable causes of admissions to the NNU between 37 and 40 weeks gestation Aim Statement To reduce avoidable admissions between 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

9 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

10 SASH Mat/Neo Dashboard HOW TO READ A RUN CHART 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. 45.0% 40.0% 35.0% The red line is the average over time Something clearly changed that affected the 'run rate'at this point. This happens to be the induction chart and at this All inductions point (Target Gap/Grow 27%) was Induction target introduced. There is still normal variation, but mostly above the long-term average Rules of a run chart data points to be meaningful 2. Less than seven consectuve points going up or down is NOT a trend (yet!) 3. Five consecutive data points above or below the mean is a run and might show effect of a change in process 30.0% 25.0% 20.0% 15.0% The data line is showing 'normal variation'. It goes up and down each month, but there is no particular pattern The green line is a target you wish to achieve - in this case the maximum, so rate should be below the line 10.0%

11 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

12 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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