Transcript Developing Safety & Quality in Maternal and Neonatal Care

Susan P Kelly
RGN. RCM. G.Dip. In Healthcare Risk Management & Quality
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Notes on Hospitals 1859
The very first requirement in a hospital is that
it should do the sick no harm.
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To give safe, effective, evidence-based care
to women and their infants.
To ensure a satisfactory birthing experience.
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For whom ???
The woman?
The partner?
The midwife?
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Who determines
What is a satisfactory birthing experience
Spontaneous onset of labour
No augmentation of the process
Free to ambulate, without being tied to a
monitor
Able to cope without analgesia
Able to be accompanied by her partner &
others as she requests
Quiet environment with minimal interruptions
Spontaneous vaginal birth of a healthy baby
Skin to skin contact and initiation of breastfeeding.
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Healthy baby
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Contented mother
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Healthy baby with an Apgar Score of 9@1,
10@ 5 minutes
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Spontaneous vaginal birth
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Intact perineum
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“There is a view in Ireland that the quality of
maternity care does not matter, as long as
you end up with a healthy baby” Jene Kelly
Acknowledging that is the most important
thing but other crucial issues are not being
addressed
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Women are not being listened to !!!
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Is a satisfactory experience a quality
experience?
Will a quality experience always be a
satisfactory experience?
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Satisfaction is a state of contentment
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Quality is a measure of excellence
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Do we prioritise quality of care?
 Safety
( avoiding harm from the care that is
intended to help)
 Effectiveness
(aligning care with science and
ensuring efficiency)
 Patient-experience
(including patientcenteredness, timeliness and equity)
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Lord Darzi for the NHS
The development by the public of an expectation
for safe, high quality healthcare and the desire by
the health system to provide same.
 Better understanding of the effectiveness of
healthcare in improving patient outcomes
 A number of international studies highlighting
the outcome of adverse events in the health
system.
 The experience in many countries of high profile
adverse incidents highlighting failings at every
level in the healthcare system.
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Lourdes Inquiry
Miscarriage Misdiagnosis Review
HIQA report on the Investigation into the
safety, quality and standards provided by the
HSE to patients, including pregnant women,
at risk of clinical deterioration, including
those provided in University Hospital Galway,
and as reflected in the care and treatment
provided to Savita Halappanavar.
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HSE report into the HSE Midland Regional
Hospital, Portlaoise Perinatal Deaths (2006 –
date)
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Mid-Staffordshire Report,
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Robert Francis, February 2013:
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A promise to learn – a commitment to act.
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“What I want is to make sure that we learn
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Mary Harney, previous Minister for Health & Children
from our mistakes, that we put in place
procedures to ensure that they can’s happen
again and when they are identified, that we
respond to the complainant in a speedy and
sensitive fashion”
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“Knowledgeable patients receiving safe and
effective care from skilled professionals in
appropriate environments with assessed
outcomes”
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Aviation: expect things to go wrong and
design to compensate. High rates of
reporting and shared learning.
Health: expect things to go right and seldom
design in safety. Low rates of reporting and
shared learning.
James Reason 1997
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Build a Safety Culture
Lead & support your staff
Integrate your risk management activity
Promote reporting
Involve and communicate with patients and
the public
Learn and share safety lessons
Implement solutions to prevent harm.
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A quality and safety culture ensures that
quality and safety is seen as fundamental to
every person working within that service.
A quality and safety culture supports and
values learning and promotes effective
governance and accountability.
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Safety is everyone's concern
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Senior leaders must drive the culture change
by demonstrating their own commitment to
safety and providing the resources to achieve
results.
The message about safety must be consistent
and sustained.
You will not change a culture overnight !
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Leaders in the organization must be visibly
committed to change and enable staff to
openly share safety information.
Staff must be supported and encouraged to
report adverse events and unsafe conditions
without fear of reprisal or belief that
reporting will not result in change.
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Promote Reflection over Recrimination
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Characterised by:
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Open Communication
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Mutual Trust
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Shared Perceptions of the Importance of Safety
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Confidence in the efficacy of preventative
measures.
We need to move from silos of safety to systems of
safety
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Effective Risk Management depends crucially
on establishing a reporting culture.
A sense of being responsible
Trust is a key feature of a reporting culture
which in turn requires the existence of a Just
Culture, which is an essential step in creating
a Safe Culture.
“How very little can be done under the spirit of
fear” Florence Nightingale
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There is a general expectation that pregnancy
and birth will be uncomplicated.
When events don’t go to plan there is often
disappointment, complaints and maybe
allegations of negligence.
Litigation may then follow.
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An open, consistent approach to
communicating with service users when
things go wrong in healthcare. This includes
expressing regret for what has happened,
keeping the patient informed, providing
feedback on investigations and the steps
taken to prevent a recurrence of the adverse
incident.
Australian Commission on Safety and Quality in
Healthcare. 2003
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Standardisation ( PPPGs)
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Effective Communication - ISBAR Report Tool
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Care Bundles
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I-MEWs , NEWs – observation charts
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Handover
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Surgical Pause
 Debriefing
 Informed
Consent
 Continuous
Professional Development
 Multidisciplinary
Training (PROMPT)
 Intuition
 Instinct
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Neonatal colleagues
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NIDCAP
Newborn Individualized Developmental Care &
Assessment Programme.
Mentoring Caregivers
 Changing hospitals
 Improving the future for newborns and their
families
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A method to understand and assure the
quality of the service we offer in healthcare.
Clinical audit:
 Monitors
 Drives
clinical quality
quality improvement
 Contributes
to improved patient outcomes.
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Described as aspects of the patient
experience that are so important to patients
and their families that healthcare providers
must perform them consistently for every
patient every time.
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Women should expect to:
always feel cared for, safe and
confident in the treatment they
receive.
 they should be treated with sympathy,
patience and respect.
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Staff should expect to be
Supported
Respected
Receive recognition for good standards
Dedication, compassion and effective
teamwork contribute to the welfare of
patients and should be valued.
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Staff, medical, midwifery/nursing are entitled
to effective leadership at every level.
Leaders must lead by example
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Recognise with clarity and courage the need for
wide systemic change
Reassert the primacy of working with patients to
achieve their desired goals
Recognise that transparency is essential and expect
and insist on it
Ensure that responsibility for functions related to
safety and improvements are vested clearly and
simply.
 Abandon
blame as a tool and trust the goodwill and good intentions of staff
 Give
staff career-long help to learn, master
and apply modern methods for quality
control, quality improvement and quality
planning.
 Make
sure pride and joy in work, not fear
infuse our staff.
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“Partnership is not about looking AT one
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Mothers & midwives have the same end goal:
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another but looking OUT together in the
same direction”.
A quality & safe experience of the miracle
that is birth.