inquiry process 4 panellists and 3 professional advisers evidence briefing written submissions from...
TRANSCRIPT
Inquiry process
• 4 panellists and 3 professional advisers• Evidence briefing• Written submissions from organisations• Oral evidence sessions• Professional evidence• Research with women (Picker Institute)• Visits
Key findings and recommendations
• Patient safety and the maternity services• Maternity services in context• Safe maternity teams• Staffing for safety• Training for safety• Guidance on safe practice• Information for safety• The role of trust boards• National structures for safety
Patient safety and the maternity services
• ‘the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care’ (Vincent 2007)
• Safety is achieved partly through the dedication and vigilance of individual clinicians, mothers and families, and partly by robust processes and systems of care.
Patient safety and the maternity services
Patient safety and the maternity services
2. Maternity services and their context
RECENT PRESSURES
Rising birth rates
Older motherhood
Problems caused by fertility treatment
Increased obesity
Survival of critical illness in childhood
More surgical intervention
Challenges presented by some forms of social & cultural diversity
ACHIEVEMENT
The fact that reductions in maternal and perinatal mortality have been achieved in spite of these pressures should be recognised as a major achievement.
8 Safe Births
3. Safe maternity teams
PROBLEMS
Interprofessional relationships
Difficulties with leadership and management
Difficulties with communication
SOLUTIONS
Clarity about team objectives and roles
Effective leadership
Clear and agreed procedures for communication
9 Safe Births
4. Staffing for safety
PROBLEMS
Shortage of midwives
Inadequate consultant cover Inexperience
Administrative overload Inappropriate deployment of
clinical skills
SOLUTIONS
The right staff in the right place at the right time
Review demand and capacity regularly
National bodies to provide simple and effective tools to help managers
10 Safe Births
5. Training for safety
PROBLEMS
Poor uptake of training
Lack of specific safety training
SOLUTIONS
Teams that work together should also train together
Simulation-based training
Safety awareness training
12 Safe Births
6. Guidance on safe practice
PROBLEMS
Guidelines not available Guidelines not useful
SOLUTIONS
Single set of evidence-based guidelines
Short summaries and one-page protocols
All staff trained to use protocols
13 Safe Births
7. Information for safety
PROBLEMS
Information not useful
Time-wasting systems
SOLUTIONS
Manageable amount of information on own and national performance
A small set of reliable information measures
Simple systems for capturing information on safety
14 Safe Births
8. The role of trust boards
PROBLEMS
Low priority for maternity
Poor focus on safety
SOLUTIONS
Prioritise safety
Educate board members
Governance structures
Improve understanding of local safety issues
Regard safety as a business imperative
15 Safe Births
9. National structures for safety
PROBLEMS
Administrative overload
Poor co-ordination
Low priority for maternity safety
CNST standards
Poor impact of recent NHS reforms
Poor regional planning & support
SOLUTIONS
Standards set and monitored by one body
Distil existing standards
Offer special support to trusts undergoing reconfiguration
Financial incentives aligned to promote the safest care
16 Safe Births
Royal College ofObstetricians andGynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers