7 Ensuring safety and quality image

Jane Raymond, Donna Hartz, Michael Nicholl

Introduction 128
Starting with terminology 129
Perception of risk 129
Challenges to safety and quality 130
Clinical risk management and uncertainty 130
Risk management in action 133
A risk assessment framework for MGP: Australia 133
The Clinical Negligence Scheme for Trusts: UK 136
Frameworks for quality and safety: Australia and UK 140
Framework for Quality and Safety: Australia 140
Clinical Governance Framework: UK 140
Specific safety and quality initiatives in midwifery 142
Midwifery Standards Review: NZ 142
Supervision of Midwives: UK 144
Post Registration Education and Practice: UK 145
Midwifery Practice Review: Australia 146
Conclusion 146
References 147

Introduction

Creating and maintaining a culture of confidence and trust in midwifery continuity of care projects often presents challenges to maternity staff and service managers. This chapter explores various practical strategies for ensuring safety and quality in midwifery continuity of care and in maternity care more generally. Some of the issues are generic (health care) while others are more specific to maternity care, midwifery practice and, finally, to continuity of care. Many of these issues are interlinked and not specific to midwifery continuity of care but are important broader aspects and included in this chapter.

We will focus on the actual application of risk assessment strategies and clinical governance related to midwifery continuity of care as developed by health services in several different countries. These perspectives and approaches reflect the ‘techno-rational approach’ (Davis-Floyd 2002) and dominant view in current discourses about risk in health care, and which are applied to the organisation of maternity services. In doing so we are mindful of another significant body of work that provides valuable social and cultural interpretations of risk assessment and of woman-centred approaches to ‘working with risk’ (Skinner 2006) and ‘being safe in practice’ (Smythe 2003), which are important concepts to incorporate into best practice maternity care. We recommend that you consider this material to aid a broader understanding of how we manage risk and work with women in the promotion of safe and effective care.

The chapter begins with some definitions and descriptions of how concepts of ‘safety’ and ‘quality’ are referred to both in the literature and in practice. Midwives, obstetricians and users of maternity services for example, see the concept of ‘risk’ differently. The challenges inherent in dealing with clinical uncertainty are explored in some detail. Frameworks for the effective management of risk are described using both service-wide and model-specific international examples. Strategically, the international quality and safety frameworks emphasise and mandate integration of services and the development of networks within maternity services. In doing so, they buttress midwifery continuity of care projects into existing mainstream services, promoting their sustainability. Strategies for ensuring consistency in practice, and the maintenance of high standards of professional care in midwifery continuity of care in Australia, New Zealand and the United Kingdom are explored at the end of the chapter.

Starting with terminology

Quality and safety literature in health uses a range of terms and definitions. Often these differ between countries and even within countries. We will start with working definitions of some of the main terms used in this area. While definitions come from specific countries, they are, in principle at least, applicable to other similar countries.

Clinical governance: Clinical governance is defined as ‘the framework through which [health] organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. The main components are clear lines of responsibility and accountability for clinical practice, clinical practice improvement programs, risk management systems, incident monitoring and professional practice performance monitoring and development systems (Department of Health 1998).

Incident: An incident is an unplanned event resulting in or having the potential for injury, ill health, damage or other loss. Any event that could have had adverse consequences but did not, and is indistinguishable from fully-fledged adverse events in all but outcome, should also be considered to be an incident. These are known as ‘near misses’ (NSW Health 2003).

Quality: Quality in relation to health care is often best described by a framework including attributes or performance characteristics. Generally quality frameworks include safety, effectiveness, patient centredness, timeliness, efficiency and equitability of care (Committee on Quality Health Care in America 2001).

Risk: Risk is defined as the chance of something happening that will have an impact upon objectives. It is usually measured in terms of consequences and likelihood (Standards Australia & Standards New Zealand 2004).

Risk management: Risk management includes the culture, processes and structures that are directed towards the effective management of potential opportunities and adverse effects (Standards Australia & Standards New Zealand 2004). Clinical risk management is risk management within the clinical context, and obstetric risk management is risk management within the obstetric context. Risk management strategies, tools or controls are initiatives aimed at eliminating or minimising identified risk.

Safety: Most definitions of safety within health care define it in terms of absence of harm. The World Health Organization (2007) describes ‘patient safety solutions’ as ‘any system, design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care’.

Perception of risk

Perhaps the biggest challenge to safety and quality in maternity service provision is the individual or, in some cases, collective perception of risk. The word risk generally has a negative connotation. When we think of risk, we usually think of some danger, jeopardy, peril, hazard, menace or threat. When discussing the risks associated with pregnancy with women we invariably focus on the negative or unwanted outcomes. Compounding this, individuals can modify their own perception of risk.

We rarely, if ever, think of risk in its broadest sense, which is best described as ‘the chance of something happening that will have an impact on objectives’ (Standards Australia & Standards New Zealand 2004). Clearly, from such a definition impacts can be both positive and negative. This is perhaps best evidenced in the financial world where the perception of risk that drives activity is generally a positive one. Risk is often specified in terms of an event or circumstance and the consequences that flow from it, and it is usually measured in terms of a combination of the consequences of an event and their likelihood (Standards Australia & Standards New Zealand 2004).

Dealing with risk in health care is also subject to these similar biases. With such a negative connotation, risk avoidance is generally the preferred method rather than the management of risk or the acceptance of risk. All too often there is a decision not to become involved in, or to withdraw from, a situation associated with risk. Indeed the perceived risk in some clinical specialties (for example, obstetrics) is sometimes blamed for workforce shortages as individuals move away from areas where personal or professional risk is perceived as high. It is conceivable that women may themselves decide not to pursue pregnancy if they perceive the risk to themselves personally, professionally or financially to be too great.

This perception of risk has impacted on the introduction of midwifery continuity of care in many places, and indeed it can affect how risk is dealt with although this has varied across different countries. Any change to service delivery models in maternity care has associated clinical, organisational, personal, professional, community or societal, financial and environmental risks. How such risks are addressed will determine the success or otherwise of the change in service delivery to enable midwifery continuity of care to be introduced and supported. Midwives in these models must face up to the significant paradox in which they practise, namely the ‘birth is normal’ paradigm within an ‘all births are risky’ context.

Challenges to safety and quality

Clinical risk management and uncertainty

Clinical risk management is a subset of the broad notion of risk management. Every action or inaction in clinical decision making may be associated with positive and negative effects. The complexity of some clinical situations means that not all risks can be anticipated or known. However even in straightforward clinical scenarios, for example whether to have a particular test or not, risk may not be adequately discussed because of gaps in knowledge or simply that there is uncertainty as to how much and what information should be communicated. Midwives, particularly in midwifery continuity of care models, confront this regularly in antenatal care provision. Box 1 outlines some of the fundamental challenges in discussing clinical risk in health generally. These need to be adapted to the context of midwifery continuity of care.

Box 1 Fundamental challenges in promoting safety and quality in health care

What are the risks?
What risks should be discussed?
How should risk be discussed with the person?
qualitative versus quantitative probability
quantitative expressions for risk
Patient errors in risk estimation
Reconciling the average and the individual
Patient preference and frameworks for decision making in practice

Let’s take a look at a practical example of what we are talking about. Read the following story from practice and reflect on how you might discuss the risks associated with this woman’s pregnancy in the context of midwifery continuity of care.

Box 2 Midwifery continuity of care for women in complex situations

Melissa is a 40-year-old woman expecting her fourth child. All her pregnancies have been difficult. She is a smoker and despite numerous attempts to give up she has been unsuccessful in trying to quit. Melissa and her partner Greg are both unemployed and they rely heavily on public transport. Both have no near relatives and have a small number of local friends. Melissa hasn’t seen a general practitioner since after her last pregnancy when she required follow up of her high blood pressure. Melissa’s three children were all born prematurely and required neonatal care for some time before returning home.

What are the issues highlighted in this story?

Clearly, Melissa has some identified risk factors and issues in this pregnancy. Encountering such a story requires good listening skills and the ability to elicit the clinical risks as well as other vulnerabilities. To ensure the best pregnancy outcomes, women need access to the model of care that best suits their individual circumstances. While pregnancy and birth are normal life events, a small number of women require timely access to higher-level care. All maternity caregivers need to be able to synthesise risk factors and other vulnerabilities, and need a comprehensive knowledge of the services available throughout their district or area so that women and their families access the ‘right’ care.

When we talk about risk and maternity service provision, including midwifery continuity of care, the issue is complicated by the socio-political events of the last 20 years where risk management and risk avoidance have become synonymous. In obstetrics, in the past decade caesarean section has been seen as the preferred clinical risk ‘treatment’. In Australia there was a professional indemnity insurance crisis in the 1990s, when obstetricians and the federal and state governments wrestled with the issue of who should fund indemnity for specialist obstetricians. This environment and these events saw the clinical practice of obstetrics, and maternity care more generally, change considerably. Then in 2000, the much criticised Term Breech Trial (Hannah et al. 2000) further added to changes in obstetric practice. All of these influences have resulted in significant changes in clinical practice (declining obstetric skills, increasing rates of placenta praevia–accreta and so on), which in turn now need to be ‘risk managed’ by the clinicians and health service. While these issues are specific to Australia, similar changes, reforms and re-organisations have occurred in other countries including New Zealand and across the United Kingdom. These changes have had similar flow-on effects on maternity care provision.

The quality and safety agenda has been slow to be embraced by some clinicians, and the concept of risk management is not well understood. Threats to personal autonomy and perceived personal risk seem to dominate any discussion on clinical risk management. Examination of clinical decision making reveals that intuition plays an important role. Such intuition involves personal ‘decision rules’ which are often built up over many years: ‘once a caesarean always a caesarean’, ‘never trust a multipara’, ‘breech plus one other risk factor equals caesarean section’ are examples of such ‘decision rules’. What appears to also operate is that intuitive decision making is more likely to occur particularly under conditions of uncertainty (Hall 2002).

With respect to clinical decision making, there are three main sources of uncertainty: technical, personal and conceptual (Hall 2002). The main technical source of uncertainty is that there is usually insufficient information to predict outcomes. The clinician–patient relationship itself can contribute to a degree of personal uncertainty. Conceptual uncertainty results from an inability to assess differing patient needs for the same resources; the application of general criteria to individual patients; or the applicability of past experiences to present patients. The net result is the tendency to uphold medical orthodoxy, that is the safest and most comfortable position is to do what others are doing. Such uncertainty can be a considerable source of stress, which can be evidenced by responses such as withdrawal from active professional involvement, black humour, bullying and harassment. Another concerning outcome from such uncertainty is that it can stimulate activity, in other words the propensity to resolve uncertainty and ambiguity by action rather than inaction. This may, in part, explain the rising intervention rates seen in maternity care in most western countries over the last 15 years.

Midwifery and obstetric education will go some way to overcoming the difficulties in decision making and dealing with uncertainty. However in order to overcome individual or group perception of risk, a generic framework for risk management is required. In Australia and New Zealand we were fortunate to have such a framework with the Australian and New Zealand Standard (2004) AS/NZS 4360: Risk Management (Box 3). This standard, while not specifically tailored for maternity services, is widely used for risk management in many contexts such as finance or insurance, and similar standards exist in other parts of the developed world. While this framework is specific to Australia and New Zealand, the essential elements will be present in almost all risk management frameworks. We have had experience of using the framework to implement and sustain midwifery continuity of care, which makes it useful for discussion.

Box 3 A generic risk management framework: Australian & New Zealand Standard AS/NZS 4360 (2004)

Risk management

communication and consultation
establishing the context
identifying risk
analysing risk
evaluating risk
treating risk
monitoring and review.

Reproduced with permission of SAI Global, http://www.saiglobal.com

Applying such a generic framework to changes in maternity service provision is possible (Tracy et al. 2005). The results of such an exercise include the establishment of a comprehensive risk register, an action plan for the proposed additional controls, the development of an evaluation tool for existing and additional controls, and the ability for additional controls to be incorporated into the plan for the service. The process of applying the framework in midwifery continuity of care models can be a positive change management strategy.

Such a formalised risk assessment is a team-based exercise that is multidisciplinary, therefore there is a high level of ownership for the outcomes. The process also ensures there is an increased appreciation by clinicians and managers of the impact and management requirements necessary for the changes to be successful. On the other hand, such risk assessments are time intensive. They require facilitation by someone who knows the process. Perhaps the most fundamental difficulty is that such frameworks are frequently in conflict with the personal decision rules of individual clinicians, which can lead to stress for other participants. Despite these challenges, a framework for risk management is essential if we are to address many of the issues facing contemporary maternity service provision, in particular midwifery continuity of care.

The next section describes our experience of maternity risk management in action, first from a facility level in Australia utilising the described risk management standard, and second on a national scale in the United Kingdom.

Risk management in action

The first example of risk management in action comes from Australia where a specific risk assessment framework was used as a strategy to help design and implement a model of midwifery continuity of care.

A risk assessment framework for MGP: Australia

The Ryde Midwifery Group Practice (RMGP) is a primary maternity service utilising caseload midwifery that enables pregnant women from Ryde, Sydney, to give birth at their local hospital and receive continuity of care from a known midwife throughout their pregnancy, birth and postnatal period. The service was developed in collaboration with consumers and doctors from the Ryde area and commenced in March 2004 (Tracy & Hartz 2005).

While appropriate and innovative by Australian standards, this midwifery-led model of care presented unknown and untested safety, organisational and operational risks in the local context. To facilitate the integration of the new service into the existing service, the Australian and New Zealand Standard AS/NZS 4360: Risk Management (Standards Australia & Standards New Zealand 2004) was utilised to develop the risk management framework.

In 2003, local integration of maternity services as well as a number of other catalysts prompted a review of maternity services at Ryde Hospital. These catalysts included diminishing obstetric analgesia–anaesthesia capabilities, falling birth numbers, concerns over the quality and safety of the existing service model; all of which were emerging in the presence of strong consumer demand for a continuing local service. They provided the impetus for a change in the way maternity services were delivered at Ryde. A local solution for this problem was sought. Establishment of the RMGP represented a reorganisation of existing midwifery services to meet the needs of women attending Ryde Hospital.

RMGP provides 24-hour midwifery-led care for women having uncomplicated pregnancy and birth. There are no on-site obstetric services. Women receive their antenatal care with the midwives at Ryde Hospital or at their home. If complications or risks are identified during pregnancy, care is transferred to a tertiary hospital, the Royal North Shore Hospital (RNSH), 12 kilometres away. In an emergency women are transferred to RNSH by ambulance or in the event of immediate threat to mother and baby, an emergency operative delivery at Ryde may be undertaken. Epidural anaesthesia is not available at Ryde, and women who need to have an elective caesarean section or who have known medical or obstetric risks do not book at Ryde. The RMGP is supported by the Ryde ‘core’ midwives, who provide 24-hour onsite backup for the births at Ryde and 24-hour postnatal care for women requiring or choosing hospital postnatal care.

The following describes the risk assessment process undertaken to develop the risk management framework for Ryde Maternity Service.

Communication and consultation

The establishment of the model was overseen by a steering committee sponsored by the Northern Sydney Health Chief Executive Officer and chaired by the General Manager of the newly integrated service comprising the two hospitals. Key stakeholders were invited to the committee including consumers, managers, and medical and midwifery staff from the community and hospital. A subgroup was formed to address risk management issues and to undertake the risk management process utilising the standard. This group was led by a Senior Risk Management Consultant from the Treasury Managed Funds (the State Health Department’s insurers). The risk management group met for six sessions over 2 months with each session taking 3 hours on average.

Establishing the context

This involved defining exactly what the group were to risk assess and so provide the terms of reference for the assessment. The context was determined to be the changes in the way maternity care was delivered at Ryde Hospital with the introduction of the midwifery group practice (MGP).

Identifying risks

To facilitate the process of identifying risks associated with the change in care provision, the current provision of care was considered, including antenatal, intrapartum and postnatal care. The changes in services provision were identified as they were the changes that were to be risk assessed. The group utilised brainstorming to identify the risks. While time consuming and demanding on the participants, particularly the clinicians involved, the process was highly effective as it allowed the identification process to draw on the individual experience and knowledge of the participants.

Analysing risks

The analysis of the risks identification was undertaken utilising the New South Wales Health Department’s Severity Assessment Code (SAC) scoring system. This system is a method for quantifying the level of risk associated with an incident depending on what the consequences of the risk could be and the likelihood of this occurring. Each risk is assigned a numerical rating from 1 to 4 with 1 being the highest risk rating (NSW Health 2003, 2004, 2006).

Evaluating risk

The risks identified were evaluated to achieve an agreed view of the priorities. Risks ranked as extreme and high risks (SAC 1 and 2) were given priority for risk management. Although other lower ranked risks were identified, due to the enormity of the project the assessment concentrated on SAC 1 and 2 initially.

Treating risk

Controls or risk management strategies or tools were identified to prevent risks from eventuating, and other possible controls or risk management that may need to be developed. Controls or risk management tools included:

Early antenatal record review.
Clinical review of cases that met specified clinical indicators by the RNS obstetrician and Ryde midwives. The clinical indicators included intrapartum or postpartum transfer of mother or baby, readmission to hospital, postpartum haemorrhage, obstetric emergency and neonatal resuscitation.
Development and utilisation of the ACM National Midwifery Consultation and Referral Guidelines (ACM 2004) for all clinical review and assessment. Using these guidelines ensures that women are assessed appropriately at their first visit to receive care at Ryde. In addition, clearly defined organisational pathway–algorithms were developed.
A review of the clinical records of women in response to emerging pregnancy-related risks was also undertaken by the RNS obstetrician and the Ryde midwives to further assess the appropriateness of ongoing care and planned birth at Ryde.
A 24-hour on-call telephone liaison–consultation with a tertiary referral centre was established.
Service specific clinical practice guidelines and protocols addressing safety in the context of the limitation of Ryde Hospital’s Clinical Facilities. For example, there is no on-site obstetric or paediatric care available except in an emergency when an obstetrician or paediatrician who is on call will be contacted for attendance.
Peer review or a prospective audit using specific clinical indicators including intrapartum and neonatal transfer, postpartum haemorrhage, and readmission of women or babies. Case summaries were reviewed by the clinical review group, which included an obstetrician, the caseload midwives, clinical midwife consultant and midwifery unit manager. This enabled continuous clinical practice improvement.

Monitoring and review

Monitoring and review was undertaken utilising established datasets and quality and safety improvement tools, some of which are:

Incident Information Management System, an electronic incident monitoring system to monitor adverse events by the state health department.
The utilisation of a clinical database system for collecting maternity data for the statewide data collection that collects and reports annual clinical outcomes for mothers and babies.
Benchmarking of outcomes with other similar maternity services utilising the clinical indicators recognised for maternity care in Australia.
Auditing of risk management tools and strategies, and peer review of clinical outcomes enables identification of areas where clinical practice improvement may be warranted.
Maintenance and auditing of risk register.

In 2006, a review of the maternity services in the area identified a rationalisation of the service was needed to ensure RMGP remained a sustainable service. The number of births at the facility and the activity of the maternity service indicated that a rationalisation of the current workforce and inpatient service provision was required to ensure the service remained viable. As a result, another risk assessment was undertaken to address changes in the provision and processes of care that a decrease in workforce and limited inpatient care would create. Controls or risk management tools as a result of this second process included:

Skill analysis and professional plan for core midwives. Some core midwives chose to leave while others chose to develop their skills where required to meet the needs of the new service.
Interim workforce plan to address the shortage of core midwives. This included reduction in inpatient numbers and reduction to one midwife per shift.
Interim security plan to protect the midwives when they were working alone in the ward. This included new security access to the ward, education to women booked with the service on contacting and accessing the service out of hours, and new telephone protocols and networks.
Marketing of service change to women booked with the service.

The risk assessment associated with the introduction of a new model of care or organisational change such as the RMGP represents a robust, transparent, inclusive and integrated process that tests and facilitates implementation of the new model within an existing organisational framework. As a result, utilisation of risk management tools and strategies has enabled the safety and quality of the service to be established, which is of paramount importance to the safety of women and their babies. This in turn promotes sustainability and viability of new models of care.

The Clinical Negligence Scheme for Trusts: UK

The framework for risk assessment of RMGP provided a small-scale example of how a risk management framework can enable safety and quality on a local scale. The Clinical Negligent Scheme for Trusts in the United Kingdom provides an example of risk management across a large national service.

Maternity care is especially likely to be exposed to risk, and in England maternity services account for a significant proportion of the number of cost of negligence claims reported each year. In 1995, in order to provide indemnity and fund the cost of clinical negligence claims, the National Health Service (NHS) in England established the Litigation Authority (NHSLA 2005) to manage the Clinical Negligence Scheme for Trusts.

Membership of the Clinical Negligence Scheme for Trusts (CNST) is voluntary and open to all Hospital Trusts (both Acute and Primary Care Trusts) in England. However the incentive to membership lies in the fact that Trusts receive a discount on their scheme contributions where they can demonstrate compliance with the Clinical Negligence Scheme for Trusts Maternity Clinical Risk Standards.

The eight CNST Maternity Standards have been developed specifically for maternity units being considered most likely to reduce harm within maternity care, and are supported by both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. The Standards are intended to contribute to the overall development and implementation of clinical governance within the Health Service. The Standards can be seen in Box 4.

Box 4 Clinical Negligence Scheme for Trusts’ Maternity Standards

1. Organisation
2. Learning from experience
3. Communication
4. Clinical care
5. Induction, training and competence
6. Health records
7. Implementation of clinical risk management
8. Staffing levels

Hospital Trusts achieve discounts on their insurance contributions through a process of formal assessment by Clinical Negligence Scheme for Trusts assessors. Each standard is subdivided into criteria and graded by the assessors at three levels. Achieving Level 1, for example, attracts a 10% discount on scheme contributions, whereas level 3 attracts a maximum discount of 30%. These levels also require staff to have an understanding of clinical risk issues, and for the maternity service to plan effectively by involving women in evaluating and developing the service as the example in Box 5 demonstrates.

Box 5 Provision of continuity of midwifery care by SureStart Local Programs

Typically, midwives working in SureStart Local Programs provided ‘outreach’ services in order to reach vulnerable groups who tended not to seek out health services. Women were encouraged to access a midwife directly early in pregnancy through drop-in sessions at local nurseries, welfare agencies, and other community locations. Material giving information about the midwifery service was available where appropriate in various languages, and advertised throughout the community in order to promote equity. Locations for antenatal care and birthing were flexible, and when women had co-existing medical or social problems, the midwife tended to take on a coordinator role maintaining close collaboration with other professionals such as obstetricians, health visitors, social workers and refugee support agencies. In many instances, this role was greatly assisted by the midwife being co-located with the primary care team at a community location. Postnatal care at home continued in many instances up to six weeks after the birth. In many cases, the provision of such flexible approaches to maternity care has been ‘mainstreamed’ by Hospital Trusts, and is now provided as part of the integrated service provision at Children’s Centres in England and Wales.

Evidence that learning from external experience has taken place forms part of the service assessment, for example the introduction of the recommendations from the Confidential Enquiries into Maternal and Child Health (CEMACH 2004) in the UK. The Report demonstrated that women living with social disadvantage and experiencing social exclusion were found to be twenty times more likely to die than women from more advantaged groups. In response, one of the main recommendations of the Confidential Enquiry (CEMACH 2004) states that vulnerable women who require coordinated care from a variety of agencies should receive the support and advocacy of a known midwife throughout pregnancy. In many instances, learning from the experience of maternal deaths in the United Kingdom has led to the introduction of flexible models of care which provide continuity from a known midwife, promote early contact in pregnancy and motivate women to continue to engage with services. Some of the features of continuity models that developed within SureStart6 local programs provide excellent examples of how midwives have successfully promoted safety and optimised clinical outcomes by providing care based on local need. These are shown in Box 5.

Midwives providing continuity of care in England, as in other parts of the world, may work in a variety of settings: public hospitals, birth centres within public hospitals, Children’s Centres in the United Kingdom, stand alone midwife-led units, the woman’s home, or a combination of all of these. The CNST Maternity Clinical Risk Management Standards also apply to midwife-led units or midwifery work settings where medical staff would not normally be present, and have been adapted to reflect these differences. Clinical governance accountability is therefore the same for all practitioners, irrespective of the setting of practice (including providing midwifery care in a woman’s home).

The eight Clinical Negligence Scheme for Trusts’ Standards and 56 accompanying sub-criteria can be viewed in full on the Clinical Negligence Scheme for Trusts website (NHSLA 2005). The importance of continuity and effective collaboration in contributing to patient safety and quality of care is evident within many of the CNST Standard criteria and examples are given below.

Standard 3: Communication

3.1.2 ‘The arrangements are clear concerning which named professional is responsible for planning and managing the woman’s care at all times.’

This point requires the name of the professional planning and managing the woman’s care to be written on her hand-held notes, which should contain entries from all professionals who subsequently provide care.

Standard 4: Clinical care

4.1.6 ‘There are clear multidisciplinary guidelines, which ensure that whenever mothers or babies move between care settings or professionals there is effective transfer of information.’

This point specifies guidelines for midwives relating to the transfer of women into hospital from the community during the intrapartum period, including women transferring to hospital from a planned homebirth setting. Box 6 describes a case study demonstrating how these two standards are met in practice.

Box 6 Meeting CNST standards for communication and clinical care

Sally is pregnant for the third time and is having midwifery care with her case-holding midwife, Lee, who is responsible for planning and managing Sally’s care. Lee has written her name and contact numbers on Sally’s hand-held antenatal record for the information of both Sally and any other care providers who may be required during the pregnancy. Sally keeps her record with her at all times and takes these notes to all her antenatal appointments. At 32 weeks gestation Sally develops symphysis pubis dysfunction and is referred to the obstetric physiotherapist by Lee. The physiotherapist assesses Sally’s mobility and makes a plan of care in partnership with her, including birth position options, which she documents in Sally’s notes. She also telephones Lee to discuss the case. The written care plan is therefore available to Lee and any other care providers at the birth, ensuring an effective transfer of information and promoting safe care.

Standard 5: Induction, training and competence

5.1.3 ‘As a minimum, all relevant obstetric and midwifery staff should attend six-monthly multidisciplinary education/training sessions, on the management of labour, fetal heart rate auscultation and CTG interpretation.’

Special mention is made of the fact that some midwives, caring for women at home in labour or in a unit where CTGs are not used, will be required to attend alternative training specific to intermittent auscultation and interpretation of the fetal heart rate. The standard also details the importance of collaborative, multidisciplinary practice sessions or ‘drills’ for dealing with emergency situations.

Box 7 describes how midwives working in team practice and specialising in home births meet the clinical risk management standards above.

Box 7 Meeting CNST standards for training and competency

Kerry is a midwife who has worked in the homebirth team of a large birthing unit for 18 months. She is required to attend clinical practice workshops which are relevant to both hospital and homebirth as last year 18 per cent of the women in her caseload were transferred to hospital care, either before or during labour. These workshops include multidisciplinary annual mandatory updates in CTG interpretation and emergency skills, and drills practice. Kerry particularly enjoys the collaborative aspect of the multidisciplinary sessions regarding the management of labour based on CTG interpretation. Kerry also attends a 6 monthly in-service on intermittent auscultation of the fetal heart rate, developed for midwives from the Birth Centre and Homebirth team, and organised by her supervisor of midwives. This session has increased the midwives’ skills and confidence, and is to be extended to all midwives in the birthing unit caring for women without risk factors in labour in an effort to promote active labour and normal birth across the whole service.

It is just as important for midwives to have the skills to deal with normality as with emergencies, and some units also provide workshops on keeping birth normal. It would be possible for such workshops to sit within the ‘skills and drills’ CNST requirements, with the aim of ultimately reducing caesarean section rates.

Frameworks for quality and safety: Australia and UK

While maternity care has some specific issues in relation to risk management in many countries, these are within an overall quality and safety framework. We now present two examples of the frameworks we are most familiar with: one from Australia and one from the United Kingdom. Both have similar underpinnings and perspectives, and it is useful to analyse each in turn to further understand how policy frameworks are being used to improve quality and safety.

Framework for Quality and Safety: Australia

In 1995, a review of the safety of Australia’s health care service indicated that there was a 16.6 per cent adverse event rate for hospitals nationwide with 51 per cent of these being preventable (Wilson et al. 1995). As a response the Australian Council for Safety and Quality was established, funded by the Australian state and territory governments, to develop a national strategic framework and associated work plan to guide its efforts in improving safety and quality across the health care system in Australia. The national framework to assess health system performance identifies nine domains. Equity to health services traverses all domains, and the framework is to be considered along with overall health outcomes and non-health determinants of health. The framework can be viewed on the Australian Commission on Safety and Quality in Health Care website (2006).

In Australia, the various state and territory governments also have quality and safety departments that lead and coordinate safety and quality initiatives and frameworks in line with the national framework. The National Quality Framework and all of its domains underpin the state and territories health departments’ quality frameworks. These in turn filter down ultimately to local facilities.

Clinical Governance Framework: UK

As in many other countries, quality in health care in the United Kingdom has been an issue of much debate over the last decade. The Government White Paper ‘A first class service’ (Department of Health 1998) outlined a 10-year program of modernisation of the National Health Service (NHS). This paper placed the issues of quality and safety at the top of the NHS agenda, and introduced the concept of clinical governance.

Clinical governance in the United Kingdom is defined as ‘a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’ (Department of Health 1998). Clinical governance is an umbrella term used to describe a number of previously fragmented processes that contribute to quality and safety as a continuous cycle of quality improvement. These are listed in Box 8.

Box 8 Quality processes incorporated in the Clinical Governance framework

Evidence-based practice
Clinical audit
Education
Research and partnership
Risk management (including risk assessment, incident reporting, incident analysis and feedback).

The clinical governance framework in the United Kingdom is intended to enable a ‘bottom-up’ approach to quality improvement, where clinicians play a key role in improving quality from a grassroots level and a ‘no blame’ culture exists. It also encourages and enables the involvement and collaboration of service users, who have a right to expect that their care will be of such quality as is consistent with safe, effective and satisfactory practice (Buckley 2004).

The National Service Framework for Children, Young People and Maternity Services (Department of Health 2004) Standard 11, for example, provides national guidance based on the needs of women and their babies during the childbearing process. The framework recommends, for example, that women’s wishes are met in regard to birth, namely continuity of care: ‘to have one-to-one care from a named midwife throughout labour and birth, preferably whom they have got to know and trust throughout pregnancy’. (Department of Health 2004, p 27)

Concern that clinical governance may limit clinical freedom to practise through excessive regulation has been expressed by a number of practitioners, including midwives. However it needs to be acknowledged that rather than limiting clinical freedom, the concept of managing risk through standardising practice can be a lever to uphold good midwifery skills. The official purpose of clinical guidelines is to provide parameters to enable safe, competent and flexible practice, allowing client choice and preferences. Produced well, these can actually serve to promote and protect a philosophy of normality within childbirth. The Royal College of Midwives’ Virtual Institute for Birth in the United Kingdom has a key objective of seeing pregnancy and birth as a normal physiological process with commitment to a positive reduction in unnecessary medical interventions. It is also committed to the promotion of midwifery skills rooted in normality across the United Kingdom (Day-Stirk & Palmer 2003). In order to achieve this vision, it is vital to create a culture where normal midwifery practice is encouraged, and clinical governance can assist in this process by legitimising an evidence-based, non-medicalised approach. An example of such a guideline can be seen in Box 9.

Box 9 Promoting and protecting normality in childbirth through clinical guidelines in the United Kingdom

The United Kingdom NICE Guidelines on the Use of Electronic Fetal Monitoring (NICE 2001) recommend the use of intermittent auscultation of the fetal heart rate in labour following an uncomplicated pregnancy, rather than the use of continuous electronic monitoring. The legitimised use of intermittent auscultation has promoted and protected normal labour and birth in the following ways:

enabled full mobility and upright positions during labour
allowed the use of the bath for pain relief in labour
reduced the likelihood of pharmacological pain relief
increased the likelihood of normal birth
reduced the need for medical intervention
enabled woman-centred care
protected the clinical skills and practice of the midwife.

Midwives working in continuity of care often find that clinical guidelines and clinical pathways need to be adapted to suit the particular circumstances and locations in which they provide care, for example in a woman’s home. The review of such guidelines is an essential part of the risk assessment and preparation for starting a midwifery continuity of care model.

Specific safety and quality initiatives in midwifery

Throughout the world, various initiatives have been developed to ensure safety and quality in midwifery. These are usually aimed at ensuring consistency in practice and the maintenance of high standards of professional care. A number of specific initiatives have been developed to ensure quality and safety, and effective clinical governance. The initiatives vary from country to country and are dependent on the local and national contexts, the historical developments in midwifery and the political agendas of the time. We will describe a number of these initiatives from Australia, New Zealand and the United Kingdom.

Midwifery Standards Review: NZ

In New Zealand, the Health Practitioners Competence Assurance (HPCA) Act 2003 was enacted to protect the health and safety of the public. Prior to the HPCA Act, legislation did not require health practitioners to continue their professional education in new skills and technologies or to demonstrate that they had maintained their competence to practise (Midwifery Council of New Zealand 2006). Potential problems with the competence of health professionals only became evident if a complaint was laid against a practitioner and a formal complaints process commenced.

The HPCA Act now provides mechanisms to ensure that all health practitioners are competent and fit to practise in their profession. This legislation applies to all health practitioners in New Zealand with separate regulatory authorities to enact the legislation for each professional group. The Midwifery Council of New Zealand is the regulatory authority for midwives.

The Midwifery Council of New Zealand administers a nationally consistent professional framework for the maintenance of the competence of all midwives irrespective of their work environment. This is known as the ‘Recertification Programme’ (Midwifery Council of New Zealand 2005). Since 2005 all New Zealand midwives who wish to retain a practising certificate are required to undertake the Midwifery Council’s Recertification Programme to demonstrate their continuing competence to practise at the minimum level required for entry to the profession. Midwives who work in caseload models must demonstrate competence annually and core (hospital-based) midwives once in every 3-year recertification cycle (Campbell 2006).

Five essential components are required as part of this Recertification Programme. They include practising across the full scope of midwifery practice, antenatal, labour, birth and postnatal; maintenance of a professional portfolio of information about practice; evidence of ongoing education and professional activities; participation in the New Zealand College of Midwives Midwifery Standards Review process; and audit. The professional portfolio for the purposes of the recertification program is the central collection point for information about a midwife’s practice and ongoing education and professional development (Midwifery Council of New Zealand 2005).

Overseen by the New Zealand College of Midwives, the Midwifery Standards Review is a compulsory and formalised professional process that focuses on professional standards. The process provides a mechanism for midwives to individually examine their practice, identify strengths and weaknesses, and develop a professional development plan to assist in the achievement of professional development goals in collaboration with colleagues and consumer representatives. A Midwifery Standards Review Panel consisting of two midwifery colleagues and two midwifery consumer representatives is responsible for undertaking the review of individual midwives and the documented evidence of attainment of these professional standards. At the completion of each review the midwife is assisted to develop a personal Professional Development Plan.

In Box 10, midwives Liz Brunton and Carey Virtue from New Zealand describe how they have used Midwifery Standards Review and processes of clinical practice audit to ensure they provide a high quality midwifery service.

Box 10 The Wellington Domino Midwifery group practice: New Zealand

The Wellington Domino Midwifery group practice was set up as a pilot in 1989 by two midwives working in a fragmented hospital system. Our model of care was based on the DOMINO service (Domiciliary ‘in and out’ at the Maternity Unit) described in the ‘Know Your Midwife Scheme’ by Flint et al. (1998). Continuity of care from a single midwife from first pregnancy contact until 6 weeks postnatal characterises the model. Women can choose homebirth or hospital birth with early discharge postnatally. Our group philosophy was, and still is, based on the belief that birth is a normal life event and that a midwife working in partnership with a woman increases the woman’s confidence in caring for herself and her baby. The practice was initially set up with four midwives working in pairs to assist one another. Identity as a group has remained key to the success of the practice. While the number of midwives has fluctuated in the 18 years since establishment, we have always had a core of four. The midwives as a group share on-call and relief for days off.

The desire on the part of the woman for a normal birth and early discharge or homebirth is an important criterion for acceptance into our practice. Ethnically and socio-economically the women in our practice are representative of the population in the service area.

Why does it work?

Wellington Domino Midwives is a group practice with a shared philosophy and practice structure that has supported midwives in the delivery of 24-hour, 7-day a week maternity care over the years.

Quality assurance has been integral, and from the beginning we were involved in Midwifery Standards Review and clinical practice audit. We designed a comprehensive electronic database so that we could demonstrate our outcomes. It was also used for practice management purposes. Low intervention rates and high consumer satisfaction have characterised our service from the beginning (Sutton et al. 2002). Evaluation of the pilot scheme (Scotney 1992) and subsequent consumer satisfaction surveys undertaken by the Ministry of Health have demonstrated that women like continuity of care and the greater flexibility of having care provided in their homes. Midwives also find satisfaction in working this way.

The current lead maternity carer model for primary maternity services in New Zealand is based to a large extent on the DOMINO model incorporating continuity of care from a single provider.

Strategies for implementation and sustainability

We set up the Wellington Domino Midwifery scheme prior to the reintroduction of autonomous midwifery practice in New Zealand. For this reason it was carefully conceived and nurtured. We worked hard at establishing good relationships with the local hospital authorities, general practitioners and obstetricians. We also ensured that a Ministry of Health funded evaluation was set up at the commencement. Careful initial planning is in part responsible for the successful implementation of the practice. Major contributors to sustainability are:

active practice management by one of the midwives
our group commitment to midwifery students’ clinical education
mentoring new graduates
the desire of the graduates to stay on and work in the practice.

Supervision of Midwives: UK

Supervision of Midwives is a statutory quality assurance process unique to the United Kingdom, first introduced through the Midwives Act in 1902. The aim of supervision within the profession of midwifery is to ‘safeguard and enhance the quality of care for the childbearing mother and her family’ (Nursing and Midwifery Council 2006). Supervision plays a crucial role in developing midwifery practice, and in ensuring safety for the public. However although safety continues to be the focus of supervision, the emphasis is more recently on supporting practice and working with midwives to ensure women receive the most appropriate care. This might include supporting a midwife providing a homebirth, needing immediate professional advice when an unexpected situation arises, or reviewing a case with a midwife who has experienced difficult clinical decision making or an unexpected clinical outcome.

Supervisors of midwives also have a responsibility to ensure effective communication between all health service staff (including medical staff ) so that all relevant issues in regard to collaborative clinical care are addressed and resolved (Stewart 2002). The issue of effective communication and collaboration is extremely important in regard to quality and safety, and is especially important in midwifery continuity of care. In addition to having a named midwife throughout the continuum of pregnancy and birth, pregnant women may require care from a variety of professionals, and all these individuals need to have clearly defined roles and responsibilities in order to provide optimal care. In the United Kingdom, clinical care plans are normally written in the woman’s hand-held record, agreed by all parties through discussion, and a selection are audited annually for quality purposes by supervisors of midwives. Supervisors will also normally encourage the retrospective, multidisciplinary review of cases as a valuable learning opportunity.

Would-be supervisors of midwives in the United Kingdom must undertake an approved program of preparation to become a supervisor. The responsibilities of supervisors are described in the ‘Midwives Rules and Standards’ (Nursing & Midwifery Council 2004a) and include being an expert practitioner, educationalist, researcher and manager. Supervisors also have a duty to become involved in risk management and clinical audit if they are to fulfil their function to ensure safety for mothers and babies. Part of the role of the supervisor of midwives is to support midwives by encouraging reflection to develop and continually improve their practice in a non-confrontational, non-judgmental way. Every practising midwife should have a named supervisor of midwives who she meets with at least annually to discuss practice and development needs, including a review of the midwife’s record keeping. Midwives new to working in models of continuity of care may require additional support, which may be initiated by either the supervisor or the midwife herself.

Post Registration Education and Practice: UK

Midwifery is a self-regulating profession, where registration is a mandatory component, but each individual midwife must take responsibility for ensuring that she is competent to practise. Owing to their occupational autonomy, midwives working in continuity of care models must be competent and knowledgeable in all areas of midwifery practice. There are two elements to ensuring clinical competence for midwives in the United Kingdom: first, midwives must notify their intention to practise on a yearly basis within the geographical region in which they will practise; and second, they must renew their registration every 3 years in order to be eligible to practise in the United Kingdom (Nursing and Midwifery Council 2004b).

However in order to renew their registration, midwives in the United Kingdom must show evidence that they have met the Post Registration Education and Practice (PREP) standards for registration (Nursing and Midwifery Council 2004b). These standards specify that midwives must have undertaken at least 5 days (35 hours) of learning in the previous 3 years. This is called the PREP standard. Practitioners can complete the required 35 hours of learning in a wide variety of ways, including any activity that contributes to maintaining and developing professional competence. Midwives working in continuity models may have a wide variety of learning needs, and may choose to access study days or independent learning on such diverse topics as, for example, domestic violence, cannulation or breastfeeding.

Practitioners must also have completed a minimum 450 hours of practice, during the 3 years prior to renewal of registration (900 hours for individuals who wish to renew both their nursing and their midwifery registrations). This is the PREP (practice) standard. The standards form a key component of clinical governance by providing a framework for continuing professional development.

Midwifery Practice Review: Australia

The development of the Midwifery Practice Review process was funded by the Australian Commission for Safety and Quality in Health Care and administered by the Australian College of Midwives. The Midwifery Practice Review process has been developed because the current processes in Australia for meeting legislative requirements for self regulation and ensuring clinical competence vary widely from one state or territory to another. There are distinct differences in the processes of renewal of registration, assessment of competence, and evidence of recent practice across the country. Midwifery Practice Review is a national approach to ensure midwives have a process to demonstrate that they meet consistent national standards (Homer & Griffiths 2006, 2007).

Midwifery Practice Review is designed to support and assist midwives to reflect on their individual practice with the guidance of specially trained peers and consumers. The process currently involves two steps. First, self-assessment and self-reflection is undertaken in preparation for the Review, including the development of a Professional Development Plan. Second, a peer-reviewed discussion occurs which includes a review of the midwife’s professional development plan. Midwives in Australia are currently encouraged to undertake Midwifery Practice Review on a 3-yearly basis.

By revisiting the key principles of midwifery continuity of care outlined in Chapter 1, it can be seen that midwives working in continuity of care have an ideal opportunity to review their practice in an especially meaningful way. First, by providing care to women throughout the continuum of pregnancy and birth, midwives are able to reflect on their practice in relation to longer term outcomes, to identify their learning needs in relation to unfolding events, and to seek feedback from the women in their care with whom they have developed meaningful relationships. Second, the development of a ‘live’ personal development plan (one that is constantly updated) is especially important for midwives providing continuity of care in view of their occupational autonomy. Third, the support at work provided by team members or partners in continuity models also provides an ideal opportunity for reflective practice and the sharing of ideas and information, which all promote professional development.

Conclusion

In keeping with other service models, and no matter where in the world they are developed, models of midwifery continuity of care require robust safety and quality strategies and frameworks to ensure that necessary standards are met. Such strategies and frameworks put the safety of mothers and babies at the centre of care, and can help to create organisational and consumer trust, confidence and support.

This chapter has shown how various initiatives have been introduced to address the challenges faced worldwide by maternity care providers in regard to reducing the risk of potential harm to women and babies. These initiatives have often been adapted to suit local requirements and the individual needs of the models of care. Where the principles of safety and quality remain the priority, the agreed standards will ultimately depend on the needs of women accessing the service and the commitment of all those involved in ensuring the highest quality of care.

We recognise that this chapter has presented one view in relation to safety, measuring competence and risk assessment. Safety and quality is a complex area and one that has a range of competing issues, cultures, viewpoints and approaches. Many will challenge our perspective and have differing views as to the best ways to ensure a safe maternity service. We acknowledge these debates and challenges, and encourage you to read widely and think broadly to ensure you can argue your own view clearly. We believe that all safety and quality initiatives in midwifery continuity of care must still maintain the principles of woman-centred care and be part of an informed discussion with women, providers and others engaged in the systems in which we work.

The next chapter highlights the challenges and difficulties that need to be considered to ensure the long-term viability of midwifery continuity of care models.

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6 SureStart local programs were part of a government-funded, time-limited project in England and Wales, which aimed to tackle child poverty and social exclusion by providing local services specifically designed for socially disadvantaged families. Targeted provision has now given way to universal services through Children’s Centres, and many innovative models of care are being ‘mainstreamed’ in the community.