Safety and Quality in Maternity Care

1. Safety and Quality in Maternity Care Denise Boulter Midwife Consultant Public Health Agency

2. How safe is the health service?

3. What we aspire to What we sometimes get

4. How Hazardous Is Health Care? (Leape)

5. How Hazardous is Maternity Care • 25,000 births • Perinatal mortality lowest for 10 years • Maternal death very uncommon However!!!!! • Approximately 20 Serious Adverse Incidents reported • Over 150 Complaints regarding maternity services • 2012 NHS compensation bill exceeded £1 billion pounds • 20% all claims are maternity 49% payout is for maternity

6. Public Health Agency Functions • Health Protection • surveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘flu • Health Improvement • Inequalities; public awareness; local interventions; partnerships; user involvement • Commissioning & Screening • Regional & local commissioning; public health priorities; wider influence; screening services • Research & Development

7. PHA Commissioning Role • PHA • Provide high quality independent professional and public health advice to support commissioning • Lead on commissioning and service improvement of agreed areas of work • Regional Board • Must consult PHA and have due regard for advice or information provided • Must not publish a commissioning plan without PHA approval • LCGs • Legislation requires LCGs to work in collaboration with PHA

8. “New Rules” for Health Care • Safety as a system property • The need for transparency and effective reporting – information a tool rather than a trial. • Testing the systems and the staff • More rapid response when things go wrong • Tracking and providing feedback about adverse events • Increased Cooperation

9. Issues • There are serious problems in quality • Between the health care we have and the care we could have, lies not just a gap but a chasm. • The problems come from poor systems…not bad people • The question is why have we not sorted it to date? • We can fix it… but it will require changes

10. The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets.

11. Ingredients • Practice • Evidence based • Care Pathways • Consistent processes • Education & training • People • Person Centred Service • Safety Forum • Support and challenge • Education and training

13. People • You are the key ingredient in making patients safe. • What can I do? • Communicate • Report incidents • Open and honest culture • Contribute to risk assessments and audit • Put safety top of your priorities – ‘ do no harm • Ask for help • Don’t take short cuts • Legible writing

14. Priorities • Strategy Implementation / Development • Maternity Strategy for Northern Ireland • Midwifery 2020 • Maternity Quality Improvement group • Maternity Hand Held Record • Regional Learning Letters

15. When it goes wrong • Death of SavitaHallappanavar • Failure to recognise she was ill • The most basic means of identifying any patients at risk of clinical deterioration is to observe the patient and regularly monitor and track her clinical observations • Lack of learning from previous similar case • 2008 Tanya McCabe • The hospital should invest in a physiological observation track and trigger system that promotes the early recognition of patient deterioration and appropriate intervention

16. Serious Adverse Incidents Definition of an adverse incident: ‘Any event or circumstances that could have or did lead to harm, loss or damage to people, property, environment or reputation’. arising during the course of the business of a HSC organisation / Special Agency or commissioned service

17. SAI criteria • Serious injury to, or the unexpected/unexplained death of: • a service user • a staff member in the course of their work • a member of the public whilst visiting a HSC facility. • Any death of a child (up to eighteenth birthday) in a hospital setting. • Unexpected serious risk to a service user and/or staff member and/or member of the public • Unexpected or significant threat to provide service and/or maintain business continuity • Serious self-harm or serious assault (including homicide and sexual assaults) by a service user, a member of staff or a member of the public within a healthcare facility • Suspected suicide of a service user known to Mental Health services (including Child and Adolescent Mental Health Services, (CAMHS) and Learning Disability (LD) within the last year. • Serious self-harm / serious assault (including homicide and sexual assaults) by a service user in the community who is known to mental health services (including CAMHS) or learning disability services within the last year. • on themself • on other service users, • on staff or • on members of the public • Serious incidents of public interest or concern relating to: • any of the criteria above • theft, fraud, information breaches or data losses • a member of HSC staff or independent practitioner

18. QUALITY, SAFETY AND EXPERIENCE SAFETY QUALITY ALERT TEAM SERIOUS ADVERSE INCIDENTS COMPLAINTS

19. Myths • The perfection myth – if we all try hard enough we will not make any mistakes • The punishment myth – of we punish people when they make mistakes they will make fewer.

20. The reality • We all make errors, no matter how much training and experience we process, or how motivated we are to do right.

21. The Message • To err is human • To cover up is unforgivable • To fail to learn is inexcusable

22. ALWAYS Ensure that the urgent doesn’t crowd out the important