Clinical Governance for Midwifery Models of Care Publication date August 2008 Functional Sub group Summary Author Branch Office of the Chief Nursing Officer This policy outlines the clinical governance arrangements to be adhered to when developing midwifery models of care. These principles must be applied by all Queensland Health employees where midwifery models of care are in place. Office of the Chief Nursing Officer Branch contact Midwifery Advisor 3234 1441 Endorsed by Approved by Applies to Audience Distributed to Patient Quality and Safety Board Director General, Queensland Health All Queensland Health public hospitals and outpatient services Midwives, general practitioners, obstetricians, Clinical Governance Units, District CEOs, State-wide Maternity and Neonatal Clinical Network, Maternity Units Review date 30 June 2013 Previous reference Status N/A Active This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this policy directive is mandatory for Queensland Health midwives.
1.0 CONTEXT Each Australian state is committed to extending and enhancing primary maternity service models as the preferred approach to providing pregnancy and birthing services to women with uncomplicated pregnancies. Women and their families must be the focus of maternity care. Primary maternity services may be provided in public maternity units, birth centres, in the community or in a combination of these settings. Care includes antenatal, birthing, and postnatal care for women with low-risk pregnancies. The safety and effectiveness of primary maternity services is underpinned by a collaborative services framework amongst care providers that ensures appropriate assessment, timely referral and access to secondary services. (Primary Maternity Services in Australia A Framework for Implementation 2008) http://qheps.health.qld.gov.au/maternityservices This policy has been developed in conjunction with the Midwifery Advisory Committee of the Office of the Chief Nursing Officer. 2.0 MIDWIFERY MODELS OF CARE: The Queensland government s response to Re-Birthing: Report of the review of maternity services in Queensland 2005, clearly states its commitment to increasing midwifery models of care in response to public demand for this type of service. The policy agenda supports midwives to work in service models of care that provide continuity of care, and models which are midwifery managed. Continuity of care and carer enables women to develop a relationship with the same caregiver(s) throughout pregnancy, birth and the postnatal period. There are demonstrated health gains from providing continuity of carer through pregnancy childbirth and the postnatal period. Midwifery continuity of care models can be organised in a variety of ways such as team midwifery, caseload and midwifery group practice, through birth centres and/or birth suites. Midwifery managed models are defined as those models where midwives are working as primary care providers through the antenatal, intrapartum and postpartum period. Each woman receives care from a nominated primary midwife who takes responsibility for ensuring that the care provided to the women is appropriate, safe and effective based on the woman s identified needs and individual circumstances. Midwifery models are one service option within a complex maternity system that can have a number of service modalities, (general practitioner, obstetrician, shared care etc) depending on the level of service available at the local health service, the wishes of the woman and her family, and the presence of complications. Midwifery models are not midwife only models, midwives do not work independently from the multidisciplinary team, rather they are collaborative models, but where for low risk women the midwife is the primary carer, who consults and refers as necessary to general practitioner or obstetrician depending on the service. 3.0 POLICY STATEMENT This policy statement should be rea d in conjunction with Queen sland Health s Midwifery Models of Care Implementation Guide 2008 When establishing a ne w model a multidisciplinary St eering Committee incl usive of inte rnal and extern al stakeholders, and medical staff is to be established, to guide implementation and ongoing monitoring of the model. Midwives, like other health professionals are a ccountable for thei r practice, and as th e midwife has primary responsibility for women and their babies within this model, the service m ust have clear clinical governance arrangements in place. Clinical gove rnance a rrangements mu st inclu de ev idence-based clinical practice guid elines, docume nted and ag reed pro cesses fo r ca se confe rencing, refe rral an d co nsultation with medical colleagues, audi t processes, data collection and outcomes reporting Page 2 of 5
4.0 CLINICAL GOVERNANCE: Queensland Health has a Clinical governance framework which includes policies, processes and accountabilities that are directed at improving patient safety and the quality, effectiveness and dependability of Queensland Health services. (QH Clinical Governance Policy, 2007 - http://www.health.qld.gov.au/quality/docs/clingovpol.pdf) This policy fits within that framework. The following Clinical governance elements must guide the implementation and delivery of all midwifery managed models of care. A model s clinical governance framework must include documents which detail the following: 4.1 Clinical practice guidelines Clinical practice guidelines must be developed collaboratively with medical colleagues. A system is required to ensure that evidence is used in the development of clinical practice guidelines for the model. Practice guidelines must be documented and approved by the appropriate district process before the model commences, and reviewed in line with EQUIP 4, Criterion 1.4.1 and Criterion 3.1.5. processes. http://qheps.health.qld.gov.au/bundy/docs/equip4_part1.pdf 4.2 Consultation and referral guidelines The Australian College of Midwives (ACM) National Midwifery Guidelines for Consultation and Referral, 2 nd edition, 2008 provide an evidenced based national framework for consultation and transfer of care between midwives and medical practitioners. These national consultation guidelines were developed with input from midwives, general practitioners, obstetricians, managers and consumers from across Australia. They are based on comparable guidelines used in other OECD countries, and a review of current evidence based practice in maternity care. The development of these national guidelines was sponsored by the Australian Council for Safety and Quality in Health Care. The guidelines clearly set out when it is appropriate for a woman to have midwifery care, when consultation must occur with a doctor, and when transfer of care to a doctor must occur. In essence the guidelines inform decision making by midwives, and provide indicators to identify situations where midwives need to carry out risk assessment and referral decisions. For convenience the guidelines are divided into four sections - booking, during pregnancy, during labour and birth and during the postnatal period. For further information on the ACM guidelines, go to: http://www.midwives.org.au/portals/8/documents/standards%20&%20guidelines/final_referral_guidelines.pdf 4.3 Clinical audit processes There must be formal processes in place for case conferencing and case review, and at a minimum, should occur m onthly. Most servi ces will r equire a wee kly or fortnig htly meeting. Case confe rencing need s to b e multidisciplinary including obstetricians/ general practitioners depending on the level of service. Clinical audit should include notification of incidents (PRIME) and review of clinical outcomes. Outcome data should be benchmarked against comparable services. Sentinel a nd SAC 1 eve nts mu st be re viewed and reported in li ne with th e Cli nical In cident Mana gement Implementation Standard 2008. http://www.health.qld.gov.au/patientsafety/documents/cimist.pdf 4.4 Risk management Standard and consistent communication protocols between midwives and medical practitioners are required in the primary service. There must also be a documented communication pathway when consultation is required between services, which includes a method of recording those consultations. (i.e. midwife in primary service to referral hospital) In addition, documented protocols are to be in place for transfer from one facility to a higher level service if required. This includes a documented system for effective transfer of information between care providers and care facilities that is well understood both in referring and referral facility. Risk management strategies must also comply with the Queensland Health Integrated Risk Management Policy 2008. http://qheps.health.qld.gov.au/audit/irm_stream/rm_policy/13355_08_2.0.pdf Page 3 of 5
4.5 Continuing professional development Midwifery models require a documented orientation and induction program. The ACM has developed a self assessment tool for midwives to assess their own professional development needs in terms of skills, knowledge and experience - Practice Development Resource: A self assessment tool for midwives. This tool is not a performance appraisal or competency assessment tool to bbe used by line managers. It is a midwife s personal assessment of practice and competency. For more information, go to: (http://www.midwives.org.au/publications/tabid/289/default.aspx) The ACM has also developed Mid Plus the continuing professional development program for midwives. This comprehensive framework can be used with Queensland Health s Performance Planning and Review processes to plan continuing professional development for midwives. (http://www.midwives.org.au/formidwives/midpluscontinuingprofessionaldevelopment/tabid/310/default.a spx) At a minimum, midwives should have completed obstetric emergency training such as Maternity Crisis Management (MaCRM) or Advanced Life Support Obstetrics (ALSO), and the Neonatal Resuscitation Program (NRP). This training should be undertaken at least once every three years. 4.6 Competency assessment. Midwives require evidence of midwifery competence in: perineal repair and speculum examination, IV cannulation and venipuncture, neonatal resuscitation, maternal resuscitation, management of shoulder dystocia, postpartum/antepartum haemorrhage, preeclampsia/eclampsia, cord prolapse and undiagnosed breech presentation. intrapartum fetal monitoring including the indications for the use and interpretation of the cardiotcograph ( CTG) Additional areas of competence may be acquired by midwives as identified and negotiated locally. The Office of the Chief Nursing Officer will work with ACM to develop a credentialing framework for midwives working in midwifery managed models of care. 4.7 Complaints management processes The complaints management process should be in line with district policies and Queensland Health s Consumer Complaints Policy 2007. http://www.health.qld.gov.au/quality/docs/conscomppolicy.pdf 4.8 Consumer participation and informed choice. Consumer participation should be encouraged in line with Equip 4 Criterion 1.4.1 that states that consumers, carers and the community have input in planning, delivery and evaluation of health services. Ideally consumer input could occur through the Steering Committee overseeing the midwifery model of care. Consumer participation should also align with the principles contained within Queensland Health Consumer and Community Participation Toolkit. (http://qheps.health.qld.gov.au/drac/docs/toolkitintro.pdf ) Care must be provided with the principle of informed choice. The midwife (or other health professional) must provide the women with sufficient information to inform the women s consent to any procedure or advice. The woman has the right to give or refuse consent to any procedure or advice. When a woman s choice is significantly at variance from professional advice or guidelines, the woman s decision and the information provided by the midwife (or other health professional) should be carefully documented and the midwife should seek further consultation according to district processes. Page 4 of 5
4.9 Evaluation All models will change and evolve over time. Implementation plans need to include processes for evaluation of models. This will include the development and reporting against key performance indicators approved by the local Steering Committee and state-wide midwifery sensitive indicators as they are developed. 5.0 REFERENCES Clinical Governance Policy 2007, Queensland Health, http://www.health.qld.gov.au/quality/docs/clingovpol.pdf Clinical Incident Management Standard (CIMIS) 2008, Queensland Health http://www.health.qld.gov.au/patientsafety/documents/cimist.pdf Credentialling Framework for Midwives, NSW Health 2005 http://www.health.nsw.gov.au/policies Queensland Health Integrated Risk Management Policy 2008 http://qheps.health.qld.gov.au/audit/irm_stream/rm_policy/13355_08_2.0.pdf Midwifery Models of Care: Implementation guide, Office of the Chief Nursing Officer, Queensland Health, 2008. ISBN 9781921447242 http://www.health.qld.gov.au/ocno/content/middy_models.pdf Midwifery Continuity of Care: A Practical Guide, Homer, C. Brodie, P and Leap, N., Chatswood, NSW, Elsevier 2008, ISBN: 978-0-7295-3844-2 MidPLUS continuing professional development Program, ACM, 2007 http://www.midwives.org.au/formidwives/midpluscontinuingprofessionaldevelopment/tabid/310/default.as px Primary Maternity Services in Australia- A framework for Implementation, Maternity Services Interjurisdictional committee, 2008 Published Victorian Government Department of Human Services, Melbourne http://qheps.health.qld.gov.au/maternityservices The Australian Council of Health Services EQUIP 4 Guide, 2006 http://qheps.health.qld.gov.au/bundy/docs/equip4_part1.pdf Unit/Departmental Clinical Review Activities: Guidelines for Basic Processes, Southern Area Health Service Clinical Governance Unit 2008, Guideline Number CGU 0001 Page 5 of 5