Monitoring performance and governance including maternity

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Monitoring performance and governance including
maternity dashboard

• Helen Scholefield
• Clinical Director Obstetrics
• Liverpool Womens NHS Foundation Trust
• Edwin Chandraharan
• Lead Clinician Labour Ward Clinical Governance
  in Obstetrics Gynaecology
• St. Georges Healthcare NHS Trust

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League Tables

• Organisational performance
• Annual Health Check
• Health Care Commission Survey
• CNST / NHSLA
• Dr Foster
• FT Benchmarking
• CEMACH Perinatal Mortality figures
• Individual performance in obstetrics
• Cf cardiac surgeons

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Clinical Governance in Practice Experience with
Maternity Performance and Governance Score Card

• Edwin Chandraharan
• Lead Clinician Labour Ward Lead for Clinical
  Governance in Obstetrics Gynaecology
• St. Georges Healthcare NHS Trust

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Background

• Hypoxic-Ischaemic- Encephalopathy (HIE)
• - Birth Asphyxia
• - Short term long term sequelae
• 6 cases / 2005 at St. Georges ? ?Excessive
• - External Review Panel ( HIE Panel)

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Areas identified by the HIE Panel for action

• Communication and Team Working
• STAN Training
• Staffing recruitment retention
• Risk Management Process
• Education and Training

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Clinical Governance

• Framework through which the NHS Organisations
  are responsible for safeguarding good clinical
  practice and continuously improving patient care
  by creating an environment, where clinical
  excellence would flourish
• How do we assess and monitor the strategies for
  clinical governance on the ground in maternity
  services?
• How to we effect changes in day-to-day practice?
• Performance Governance Score Card

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St. Georges Experience with 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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Can Robust and Effective Monitoring through the
Maternity Dashboard help improve Quality of
Patient Care?
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Example of an Obstetric assurance presentation to
Board

• Helen Scholefield
• Clinical Director, Obstetrics
• Liverpool Womens NHS Foundation Trust

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Obstetric Risk Management Strategy

• Annual update August 07- Needs ratifying by CGC
• Will be monitored through the Maternity Risk
  Management Group.
• Associated reports and action plans will be
  monitored by the Risk Management Committee.
• Risk related reports from the Directorate will be
  further monitored by the appropriate senior
  committee in the Trust.
• Staff will be informed of the principles of this
  strategy and all associated policies at local
  induction, annual training and workshops
• Adherence to the principles of the strategy will
  be monitored through associated reports, action
  plans, changes in practice and the PDR process

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Clinical Indicators
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Clinical Indicators
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Perinatal Mortality

• Stillbirth
• 2004

• Neonatal Mortality

2005
2004
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Comparison with other units with similar referral
patterns (2004)
Unit SB rate Regional rate
LWH 6.5 5.6
Sheffield 6.5 6.4
QCCH 8.3 6.7
St. Michaels Bristol 7.8 5.4
BWH 7.9 5.8
Stillbirth rates for Liverpool Women's Hospital
NHS Foundation Trust (LWH), although higher than
the National rate of 5.7/1000, are similar to
other tertiary referral centres.
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Stillbirth rate corrected for women who
originally booked and delivered at LWH
Year No. of SB Referrals/ IUT No. originally booked to deliver at LWH Overall SB rate for LWH
2004 52 8 5.6/1000 6.5/1000
2005 47 4 5.3/1000 5.8/1000
2006 53 8 5.6/1000 6.6/1000
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Can we do better?
2004 2005 2006 OVERALL
Normal care 33/52 (63) 32/47 (68) 37/53 (70) 67
Different management would not have altered outcome 4/52 (8) 2/47 (4) 5/53 (9) 7
Different management may have altered outcome 14/52 (27) 11/47 (23) 9/53 (17) 22
Different management would reasonably be expected to have altered outcome 1/52 (2) 2/47 (4) none 3
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Themes

• Themes
• The major themes identified for were
• Undetected intrauterine growth restriction/small
  for gestational age babies
• Late bookers, unbooked women and women who did
  not attend antenatal visits
• Late transfers for antenatal care from other
  areas
• CTG misinterpretation
• Other issues identified were
• Failure of staff to recognise relevance of past
  obstetric history or complexity of current
  pregnancy
• Fetal assessment in large women

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Recommendations
Ensure consistent use of fetal growth charts Ensure robust referral system when suspicion of growth restriction Guidelines- for fetal growth assessment to be updated (to take into account women with BMI gt35 ) and consideration given to charts which are more likely to detect antenatal growth restriction
DNA policy should be robustly implemented. GPs, Community midwives, Health Visitors to be updated on policy. Unbooked women and late bookers to be prospectively discussed in ANC ACE reviews
Guidelines- Antenatal care of women who transfer late in pregnancy and have relevant obstetric history
CTG updates and K2 to include sessions on interpretation of computerised CTG for complex cases such as twins and large women, visual interpretation of computerised CTG which fails criteria and use of clinical context in management
Increase awareness of women re symptoms of obstetric cholestasis (using leaflets, maternity notes)
Continuous audit of stillbirths so themes can be identified
Recode using other published classification for deaths classified as unexplained such as RECODE, Await CEMACH PNM surveillance report 2005, which will aim to report on fetuses that were small for gestational age and the presence of fetal growth restriction
Continue to benchmark with similar Trusts
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Conclusions

• How do we improve the detection of the small for
  gestational age fetus at risk of stillbirth?
• How we improve the stillbirth rate for obese
  women?
• How do we improve antenatal CTG interpretation
  within the context of the complexity of the case?
• How do we improve our services for vulnerable
  women, women who book late or transfer care late
  in pregnancy?
• We need to look at the relationship between
  obstetric practice and high neonatal death rate

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Adverse Clinical Events
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Adverse Clinical Events
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Adverse Clinical Events Themes Trends
Jan- Mar 07 Jan- Mar 07 Oct- Dec 06 Oct- Dec 06 Jul- Sept 06 Jul- Sept 06 April-June 06 April-June 06
Clinical Management 38 Medication 54 Medication 60 Medication 43
Medication 33 Communication 43 Clinical Management 47 Pt records / identification 37
Staffing levels 27 Pt records / identification 36 Admission / Discharge 45 Clinical Management 27
Communication 25 Clinical Management 34 Staffing levels 44 Admission / Discharge 24
Pt records / identification 24 Staffing levels 33 Pt records / identification 29 Communication 19
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Changes in Practice and their impact

• Profile and communication relating to anaesthetic
  cover for 24 hour Improved epidural provision
• Improved relations communication between
  intrapartum areas and deployment of staff, -
  reduction in number of delayed IOL
• Meditech facility relating to PCI identification
  subsequent care plans for vulnerable women and
  babies utilised - No further ACEs
• Booking assessment sheet sent to CMW, reducing
  risks of DNA fewer incidents
• Anti D policy change in procedure- No further
  ACEs
• Formal record of identification at birth by 2
  individuals - reduction in number of babies
  identified incorrectly following
• Transfer of management of TC to NICU - Admission
  and transfer improved
• Medication errors decreased following individual
  feedback
• TTO storage/ prep area identified -No further
  ACEs
• Training of clerical staff - Improvement in
  patient record incidents and reduction in record
  unavailability

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Risk Register

• 60 on register
• High risks none
• Medium and low risk where significant e.g. trends
  
• Medication Errors Medicines Management Working
  party
• Patient Records Out of hours access to Aintree
  notes
• Lone worker system
• Poor ergonomics
• Obstetric Secretaries
• Specialist MW

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RR- Changes in practice (controls) and impact of
changes

• Discharge arrangements
• Emergency call system on Jeffcoate/ MLU
• Sinks replaced on Postnatal wards
• Improved liaison and formal handover between
  Intrapartum areas
• Improved provision of epidural - reduced number
  of patient complaints and incidents reported
• Identified process for robust patient information
  review
• All Obstetric Guidelines now accessible via Trust
  intranet
• Development of Obstetric Risk Management
  Newsletter

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Complaints
Jan- Mar 07 Oct- Dec 06
Upheld 7 4
Partially Upheld 1 4
Not Upheld 3 6
Total 11 14

• Themes
• Staff Attitude
• Lack of support on PN ward
• Assessment room
• Wrong documentation

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Clinical Audit

• Audit programme on target to meet CNST NHSLA
  requirements

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NICE Guidance

• Guidelines
• Compliant with
• Antenatal Care
• CS
• AN PN Mental Health
• PN Care

• IPG
• Compliant with
• Amnioinfusion
• Pleuro- amniotic shunt
• Bladder shunt
• Cell salvage
• Other procedures with IPG not done

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NSF

• The Action plan has been reviewed regularly
  and updated and is now complete and the
  Directorate declared compliance with
  recommendations

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Confidential Enquiries

• Project 27/28. Joint action plan led by Neonatal
  Directorate developed in response to CESDI
  recommendations Action plan completed.
• CEMACH . Action plan developed in Response to
  National Confidential Enquiry into Maternal and
  Child Health 2004 (2000-2002) Compliant
• Non-compliance
• Awaiting Action plan for CEMACH Diabetes Survey

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HCC Northwick Park Reports

• Action plan in place
• Areas of partial compliance
• Consultant Staffing
• Hours of DS cover
• Dedicated cover for CS lists
• MW staffing shortage on DS
• 24 Hour theatre cover
• Interventional radiology

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Infection Control

• Concerns re compliance due to impact of key staff
  leaving.
• Ward managers have been informed of where action
  plans are out of date and audits have not taken
  place.
• They arranging these and liaising with their link
  midwives
• Trial of use of PDA for area audits to improve
  timely feedback
• Will utilize Theatres CC spread sheet which
  identifies when audits are due with hyper links
  into Winning Ways and Saving Lives when these
  assessments are also due
• Action to take place
• Complete audits
• Develop action plans for any lack of improvement
  in practice identified, with additional controls
  put in place where neded.

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Training

• NHSLA General
• Compliant Infection Control, Risk Management
  Incident Reporting, Health Safety training,
  Manual Handling, Blood Transfusion and Basic Life
  Support, corporate/ local induction.
• Partial compliance
• Conflict resolution
• Being Open
• Protecting Vulnerable adults
• Safe Guarding Children

• CNST Maternity
• 76 of Midwifery staff completed obstetric
  emergency training
• Expect to reach 90 target by Jan 08
• Junior medical staff completed as part of
  induction
• Consultants currently updating. No figures
  received from PG

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• NHSLA General Standards CNST Maternity
  Standards
• All non- compliance noted in NHSLA and CNST
  action plans with identified individual
  responsibility and time frame for submission.
• Anticipate compliance at level 3
• Standards for Better Health
• All non- compliance noted in Standards for Better
  Health action plan with identified individual
  responsibility and time frame for submission.
• (see Risk Management Assurance Report-
  circulated)