Transcript Monitoring performance and governance including maternity ‘dashboard’

Monitoring performance and governance
including maternity ‘dashboard’
Helen Scholefield
Clinical Director Obstetrics
Liverpool Women’s NHS Foundation Trust
Edwin Chandraharan
Lead Clinician Labour Ward & Clinical Governance in
Obstetrics & Gynaecology
St. George’s Healthcare NHS Trust
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
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. George’s Healthcare NHS Trust
Background
Hypoxic-Ischaemic- Encephalopathy (HIE):
- ‘Birth Asphyxia’
- Short term & long term sequelae
• 6 cases / 2005 at St. George’s ? ?Excessive
- External Review Panel (‘ HIE Panel’)
Trend of HIE
3.5
Total number of deliveries
4500
3.0
4000
2.5
3500
3000
2.0
2500
1.5
2000
1500
1.0
1000
0.5
500
0
0.0
2000
Deliveries
2001
2002
2003
Total number of HIE
2004
2005
HIE c ases of grade 2 and 3
HIE cases per 1000 deliveries
5000
T
Total HIE cases
R
A
LY
R
A
LI
A
C
E
o
n
N
E
S
T
N
C
E
A
N
n
IN
E
L
D
IT
FR
E
U
B
S
W
D
R
eg
io
Y
E
H
R
B
S
T
E
E
D
IC
n
t
A
U
re
LE
S
G
HIE in the world
9
8
7
6
5
4
3
2
1
0
HIE cases grade 2 & 3
Areas identified by the ‘HIE Panel’ for
action
•
Communication and Team Working
•
STAN Training
•
Staffing: recruitment & retention
•
Risk Management Process
•
Education and Training
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
St. George’s Experience with Performance &
Governance Score Card ‘Maternity Dashboard’
•
Designed by Prof. Arulkumaran & Team –Northwick Park
•
Recommended by CMO’s Report
•
Looks at Activity, Staffing, Clinical Risk indicators, User feedback (e.g.
complaints)
Can Robust and Effective Monitoring
through the Maternity Dashboard help
improve Quality of Patient Care?
Example of an Obstetric
assurance presentation to
Board
Helen Scholefield
Clinical Director, Obstetrics
Liverpool Women’s NHS Foundation Trust
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
Clinical Indicators
Obstetric Clinical Indicators
2006
Women giving birth
babies born
April-Jun
07
1881
1904
Jan- Mar
07
1849
1899
2006
2005
2004
2003
2002
2001
2000
8055
8221
7917
8077
7695
7849
6137
6260
5827
5958
5820
5951
5921
6037
Clinical Indicator
Shoulder Dystocia
Erbs palsy
Third Degree Tears
Apgars<4 at 5 mins
Cord pH <7
HIE
Caesarean sections
Stillbirths
Neonatal Deaths
Neonatal Deaths(LWH
booked)
Spontaneous late fetal
loss 22- 24 weeks
Therapeutic Abortion 2224 weeks
Livebirths delivered
below 28+0 weeks
HDU admissions
/1000
16.4
0.5
19.1
3.1
4.2
/1000
12.9
0.5
11.8
2.1
5.7
/1000
15
/ 1000
12.1
6
13
5.2
13
/ 1000
11.8
/ 1000
8.9
8.4
6.3
14
6.1
10.5
268
4.2
5.7
2.7
241
6.2
4.8
/ 1000
14.4
1.4
13.7
5
7
2.4
233
6.8
7.3
3
/ 1000
12
2
13
4.3
6
240
9.9
8.9
6.8
/1000
15.3
0.12
15.4
4
7
2.5
238
5.8
7.4
6.1
232
6
6.7
3.1
238
5.6
8
3.7
208
5.8
6
3
217
5.9
10.5
4.2
1.0
1.1
1.5*
2.7*
3.0*
2.2*
1.8*
0.4
1.5
2.2**
3**
3.2**
1.2**
3.9**
8.6
8
13.5
13.9
10.8
0
0
0
12
3
5
9.4
13.1
8
10.9
45
54
43
38
Maternal ICU Transfer
0.5
1
1.1
0.4
1.8
Maternal Death
(direct & indirect)
0
0
0
0
0
CEMACH
figures
BWH
04/05
6651
6774
QCCH
2004
4940
5098
/1000
/1000
SMH
03/04
4468
4573
/1000
20
5.77
3.66
228
7.9
6.6
316
8.6
10
14.7
10.0
0.13
(direct &
indirect)
0.3
(2
indirect
)
*previous years reported as fetal deaths 20- 24 and spontaneous miscarriage 20 - 24 weeks** previous years reported as therapeutic Abortion 20- 24 weeks
200
0.4 (2)
0.7 (3)
Clinical Indicators
Cord pH < 7.0 2001- 2007
Maternal death
( Direct & Indirect)
14
Jan- Dec 01
12
Jan- Dec 02
10
8
Jan- Dec 03
0.7
0.6
CEMACH
Jan- Dec 04
0.5
LWH
6
Jan- Dec 05
BWH
4
Jan- Dec 06
0.4
0.3
2
Jan-Mar 07
0
Apr- June 07
0.2
0.1
0
SMH
QCH
Perinatal Mortality
Stillbirth
Neonatal Mortality
2005
2004
2004
Comparison with other units with similar referral
patterns (2004)
Unit
SB rate
Regional rate
LWH
Sheffield
6.5
6.5
5.6
6.4
QCCH
St. Michael’s
Bristol
8.3
7.8
6.7
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.
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
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%
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
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
Adverse Clinical Events
Oct- Dec 06
Total
Jan- Mar
07
333
406
July- Sept
06
377
April- June
06
344
Adverse Event
Near-miss
249 (75%)
84 (25%)
303 (75%)
103 (25%)
239 (63%)
138 (37%)
153 (54%)
129 (46%)
Very Low
Low
Moderate
High
97 (29%)
182 (55%)
53 (16%)
1 (<1%)
133 (33%)
206 (51%)
65 (16%)
2 (<1%)
116 (31%)
165 (44%)
95 (25%)
1 (<1%)
72 (25%)
139 (49%)
70 (25%)
1(<1%)
Appropriate care
131 (53%)
148 (49%)
127 (53%)
84 (55%)
Potential for
improvement
118 (47%)
155 (51%)
108 (47%)
69 (45%)
Adverse Clinical Events
Jan - March 04
160
April- June 04
140
July- Sept 04
Oct - Dec 04
120
Jan-March 05
April- June 05
100
July-Sept 05
80
Oct-Dec 05
Jan- March 06
60
April-June 06
40
Jul-Sept 06
20
Oct- Dec 06
Jan-Marc 07
0
Reports/month
Near Miss %
High Risk %
Moderate Risk %
Potential for
improvement %
Adverse Clinical Events Themes &
Trends
Jan- Mar 07
Oct- Dec 06
Jul- Sept 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
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 ACE’s
•
Booking assessment sheet sent to CMW, reducing risks of DNA – fewer incidents
•
Anti D policy change in procedure- No further ACE’s
•
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 ACE’s
•
Training of clerical staff - Improvement in patient record incidents and reduction in record unavailability
•
Training on CD procedures and separate CD record book for theatre - No further reports of noncompliance
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
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
Complaints
Upheld
Partially Upheld
Not Upheld
Total
Jan- Mar 07
7
1
3
11
Themes
Staff Attitude
Lack of support on PN ward
Assessment room
Wrong documentation
Oct- Dec 06
4
4
6
14
Clinical Audit
Audit programme on target to meet
CNST & NHSLA requirements
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
NSF
The Action plan has been reviewed
regularly and updated and is now
complete and the Directorate declared
compliance with recommendations
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
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
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.
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:
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
–
–
–
–
Conflict resolution
Being Open
Protecting Vulnerable adults
Safe Guarding Children
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)