Denise Boulter Midwife Consultant Public Health Agency.

Safety and Quality in Maternity Care Denise Boulter

Midwife ConsultantPublic Health Agency

How safe is the health service?

What we aspire to What we sometimes get

How Hazardous Is Health Care? (Leape)

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

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lo

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REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

How Hazardous is Maternity Care 25,000 births Perinatal mortality lowest for 10 yearsMaternal death very uncommonHowever!!!!!Approximately 20 Serious Adverse Incidents

reportedOver 150 Complaints regarding maternity services 2012 NHS compensation bill exceeded £1

billion pounds 20% all claims are maternity 49% payout is for

maternity

Public Health Agency FunctionsHealth Protection

surveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘flu

Health Improvement Inequalities; public awareness; local interventions;

partnerships; user involvement

Commissioning & ScreeningRegional & local commissioning; public health priorities;

wider influence; screening services

Research & Development

PHA Commissioning RolePHA

Provide high quality independent professional and public health advice to support commissioning

Lead on commissioning and service improvement of agreed areas of work

Regional BoardMust consult PHA and have due regard for advice or

information providedMust not publish a commissioning plan without PHA

approvalLCGs

Legislation requires LCGs to work in collaboration with PHA

“New Rules” for Health Care

Safety as a system propertyThe 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 wrongTracking and providing feedback about adverse

eventsIncreased Cooperation

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 peopleThe question is why have we not sorted it to

date? We can fix it… but it will require changes

The First Law of Improvement

Every system is perfectly designed to achieve exactly the results it gets.

Ingredients Practice

Evidence basedCare Pathways Consistent

processesEducation &

training

People Person Centred

ServiceSafety Forum Support and challenge Education and training

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 harmAsk for help Don’t take short cuts Legible writing

PrioritiesStrategy Implementation / Development

Maternity Strategy for Northern IrelandMidwifery 2020

Maternity Quality Improvement groupMaternity Hand Held Record Regional Learning Letters

When it goes wrong Death of Savita HallappanavarFailure 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 case2008 Tanya Mc Cabe

The hospital should invest in a physiological observation track and trigger system that promotes the early recognition of patient deterioration and appropriate intervention

Serious Adverse IncidentsDefinition 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

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

QUALITY, SAFETY AND EXPERIENCE

SAFETY QUALITY ALERT TEAM

SERIOUS ADVERSE INCIDENTS COMPLAINTS

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.

The reality We all make errors, no matter how much training and experience we process, or how

motivated we are to do right.

To err is humanTo cover up is unforgivableTo fail to learn is inexcusable

The Message

ALWAYSEnsure that the urgent doesn’t

crowd out the important