NHSLA DNV Launch Seminar CNST Standards

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NHSLA/ DNV Launch Seminar CNST Standards

• The Relevance of the CNST Maternity Standards for
  the RCOG
• 11th March 2009
• Tahir Mahmood FRCOG
• Vice President Standards

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What implementation of the standards can
achieve?A World Class Clinical Service

• Fairequally available to all
• PersonalisedTailored to the needs and wants of
  each individual
• EffectiveFocussed on delivering outcomes the
  best in the world
• SafeGiving patients and public the confidence
  they need in the care they receive.
• AmbitiousResponsive to the aspirations of the
  patients and the public
• Shared vision (Darzi 2007)

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Role of RCOG in Setting Standards

• Clinical Care
• Service Provision
• Risk Management
• Teaching and Training

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Role of RCOG in Setting Standards

• Clinical Care
• Obstetrics
• Safer Childbirth (2007)
• Standards for Maternity Care (2008)
• Maternity Balanced Score Card (Dash Board) 2008
• Responsibility for Consultant on Call (2009)
• Intrapartum Care Bundles Joint Project with NPSA
  (2007-2009)
• Gynaecology
• Standards for Gynaecology (2008)
• (Early Pregnancy Care)

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Role of RCOG in Setting Standards

• Service Provision
• The Future Role of Consultant (2005)
• Working Time Directive Solutions W/P (RCOG/RCPCH)
  2008
• Maternity Services Future of Small Obstetric
  Units (lt2500 deliveries) RCOG Position Paper
  (2008)
• Supporting Health Care Commission (Care
  Commission) for Maternity Services Annual Check
• Supporting NCAS Services/Colleagues in
  Difficulty

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Role of RCOG in Setting Standards

• Risk Management
• Confidential Enquiries Into Maternal Deaths
• NICE (NCC-WCH) National Guidelines
• Maternal Morbidity Audits (Scotland) RCOG/RCM
• ORCA (Regional variations in caesarean section)
  RCOG
• Quality Matrices Quality Accounts (new work
  stream)
• Supporting work of NHSLA CNST Maternity
  Standards

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Role of RCOG in Setting Standards

• Teaching and Training
• Training Standards RCOG curriculum
• Standards for Trainers PMETB
• Responsibility of Consultant on Call (2009)
• RCOG Trainees Survey (2008-09)

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Direct maternal mortality 1952-2005(rate per
million maternities)
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Direct and indirect maternal mortality
1987-2005(rate per 100,000 maternities)
Direct
Indirect
9
8
7.8
7
6.4
6.1
6
6.1
6.1
5.5
5.3
5
5
4.3
4
3.9
3.7
3
2
1
0
'87
'90
'93
'96
'99
'02
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Direct and indirect maternal mortality
2000-2005(rate per 100,000 maternities)
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Why do mothers die? substandard care (direct
deaths)
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(No Transcript)
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Rates of severe maternal morbidity
Near missdeath ratio, 561 (triennium) SPCERH
2007
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CommunicationWho was involved in hands-on
care?(N 512)
600
5
73
2
1
3
500
60
400
36
8
300
200
100
0
Obs.
Obs. SR
Obs. Reg
Obs. SHO
Anaes.
Sen. M.W.
Jun. M.W.
Consultant
84
98
98
98
99
100
71
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• RCOG provides evidence base to tackle the
  challenge
• CNST Standards for Quality Assurance

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So, why these new documents ?

• For the first time all the standards in one
  document from prepregnancy care to transition to
  parenthood, produced jointly by four colleges

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• Safer Child Birth Standards

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Safer Childbirth

• Standard 1 Organisation and Documentation
• Comprehensive evidence based guidelines and
  protocols for intrapartum care to be reviewed
  at least every 3 years
• There is written evidence of risk management
  policy, including trigger incidents for risk and
  adverse incident reporting
• An evaluation of midwifery and obstetric care
  through prospective audit of case notes to
  improve outcomes annual report

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• Standard 2 Multidisciplinary Working
• Local multidisciplinary maternity care teams
• A labour ward forum
• Standard 3 Communication
• An effective system of communication between all
  team members

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• Standard 4 Staffing Levels
• Key Issues 2009
• Prospective consultant obstetrician cover for
  labour ward for Holidays
• Units delivering gt2500 women should be working
  towards 60 hrs consultant presence
• Smaller units lt2500 deliveries should conduct a
  risk assessment and are strongly recommended to
  have a 40 hr consultant presence

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Morbidity Mortality increases without direct
care supervision

• Remote surveillance may lead to more morbidity

• Immediate attendance by senior would reduce
  morbidity
• Consultant Presence would promote more normal
  deliveries - improve quality and safety
• Analogy Pilot Trainee pilot maternity
  services most times staffed by trainee doctor
• TRAINING CTG e-learning tool free for NHS
  staff

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Proposed Obstetric Staffing Targets
(2007-2010)(Adapted from The Future Role of the
Consultant 2005)
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• Standard 5 Leadership
• Lead consultant obstetrician
• Lead labour ward manager
• One WTE consultant midwife to 900 low risk women
• Standard 6 Core Responsibilities
• One to one care from a midwife in established
  labour
• Frequency of ward rounds by consultant on call
  after 5 pm and on the weekends

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• Standard 7 Emergencies Care
• The consultant obstetrician must be contacted
  prior to emergency caesarean section and must be
  involved when a patients condition gives rise
  for concern and attend as required.
• A consultant obstetrician should be available
  within 30 minutes outside the hours of consultant
  presence

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Responsibility of Consultant on Call(RCOG advice
2009)

• Labour ward duties (safer childbirth)
• Must attend
• Major Post Partum Haemorrhage
• Eclamptic fit
• Collapsed patient
• Major placenta praevia
• Return to theatre -Laparotomy
• When trainee asks for it
• Be present (depending upon trainees experience)
• Trial of instrumental delivery/2nd stage C/S
• Twins/preterm labour C/S / vaginal Breech
  delivery
• C/S at full dilatation/ for Transverse lie/ BMI
  gt40

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• Standard 8 Training and Education
• Adequate clinical support and supervision
• Training Needs Analysis CTG Training in house,
  Fire Drills, staff skills inventory.
• Standard 9 Environment and Facilities
• Facilities in birth settings should take account
  of the womens needs and the views of service
  users
• Standard 10 Audit
• Audit of birth outcomes, evaluating linked
  clinical care, any changes and trends analysis

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Performance Governance Score Card Maternity
Dashboard

• Designed by Prof. Arulkumaran Team Northwick
  Park
• Recommended by CMOs Report
• Looks at Activity, Staffing, Clinical Risk
  indicators, User feedback (e.g. complaints)

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Ensuring high quality safe care. Tool for
Commissioners, Providers, Consumers and
Regulators
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CLINICAL GOVERNANCE
Leadership Administrative Clinical
(Med/Nurses/MW/ AHW)
Professionals (Revalidation)
Accreditation of Services
EB Guidelines Education Training Audit
Patients Complaints
Clinical Risk Management
Research Into most vulnerable
Planning is power
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How CNST Monitoring will help to implement RCOG
Standards?

• Documentation Review of case notes to assess
  adherence to guidelines- Eclampsia, PPH,Urgent
  C/S, Diabetes, DVT management, operative vaginal
  birth.
• Communication Evidence of MDT working in a case
  of severe pre-Eclampsia
• Risk assessment of individual patient in labour
• Risk Management strategy in place to learn from
  adverse outcomes
• Hand over of care
• Guidelines development and regular review
  timeline
• Skills Drills training needs analysis.

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• Risks/ Constraints RELATED TO IMPLEMENTATION OF
  SAFER CHILDBIRTH STANDARDS

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Staffing Issues

• Role of Post CCT (not holding consultant
  contract)
• El C/S op list
• Gynae on call duties
• Recruitment issues funding issues as labour
  ward duties are not a top priority

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Issues Identified

• Labour Ward Consultant Responsibility
• Principle Acute obstetrics and gynaecology
  should take a priority
• Prospective Cover for Annual Leave (compliance
  demonstrated)
• Built in rota and job plan
• No other fixed commitments especially operating
  list
• Arrangements will vary according to size of unit
• Adequate workforce calculations (esp. PAs for
  weekend on site work)
• Post CCT as part of solution

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A Model for Consultant ObstetricianPresence in a
Medium Sized Unit (4000 births)
Only one member of team can be on leave Post on
call morning session is an SPA (12
basis) (Ref Safer Childbirth 2007)
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Issues Identified

• Evidence of unit policy
• Short Term Sickness
• Ad hoc arrangement
• Policy in place
• There should be someone who can physically do the
  ward rounds and be available when required
• Long Term Sickness
• Long term sickness should be covered formally

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Issues Identified

• 
  Business Plan
• Unit gt2500
• Direction of travel ? 60 hrs cover 98 hours for
  gt6000
• There should be weekend cover in place for labour
  ward rounds
• Prospective cover for annual/study leave
• Unit lt2500
• Direction of travel ? 40 hrs cover
• When on call ?am? rounds elective C/S list
• Pm session could be an admin PA/SPA
• Variables
• Complexity of case load
• Geographical isolation

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Issues Identified

• El C/S list
• On call consultant (lt2500)
• or
• 2nd on call consultant (gt 6000)
• (depending upon the intensity of work, level of
  junior support, and acute gynaecology workload)
• Gynaecological Emergencies
• Consultant on call for labour ward
• or
• 2nd on call team only for gynae units
• Variable Possibility for very large units at
  present

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Implementation of Safer Childbirth Targets

• Flexibility is the key
• Will need slippage agree
• Not enough trained CCT holders
• WTD solutions are being sought
• Recent economic downturn
• Recruitment cycle may take up to 6 months
• Contingency plans to address on-going shortfall,
  if any
• Contract issues esp. for 24 hr consultant
  presence (remuneration, job planning, time off
  post on all)

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Service Reconfiguration Debate and Future
Staffing Levels (Business Plan)

• Issue
• Planned changes agreed or not?
• Should it affect recruitment?
• Solutions
• How to provide current service?
• assess future needs!
• Scenario
• Unit size after reconfiguration gt4000 or gt6000
• Recruitment should take account of future needs
  (98 hrs/168 hrs cover)

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Implementing Safer Childbirth RecommendationsJuni
or Staffing Levels

• Constraints especially for units lt2500
• Possible reduction in training numbers
• Alternative solutions ? consultant delivered
  service
• Large units (ST6-7)
• There should be a clearly defined policy within
  the unit for delegation of responsibility

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Key Message

• A clearly defined business plan to address
  staffing short falls- end points
• Annual audit of Medical and Midwifery staffing
  levels in the unit
• Contingency plans for sickness absence
• Increased work load challenges supported by the
  use of Maternity Dash Board
• Evidence of consultant involvement in the care of
  high risk patients in labour

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