Preparing for CNST Maternity Levels 1, 2 and 3: Experience of the Liverpool Women’s Hospital

1. Preparing for CNST Maternity Levels 1, 2 and 3: Experience of the Liverpool Women’s Hospital Helen Scholefield Consultant Obstetrician & Lead for Clinical Risk Management

2. Where are trusts now? Why separate maternity standards? Why aim higher Team approach The standards Difficult level 1 criteria Level 2 & 3 criteria How we covered them Feedback from assessors where we could improve

3. Trust CNST Maternity Levels

4. Why separate Maternity Standards

5. Organisation with a Memory 2000 • Reduce risk in Obstetrics by 25% by 2005

6. 8 standards • Organisation • Learning from experience • Communication • Clinical Care • Induction, Training and competence • Health records • Implementation of CRM • Staffing levels

7. Incentives for achieving higher levels • Improve safety for patients • Staff ,ownership of CRM through training, teamwork, avoid being second victim of error, sense of shared achievement • Financial- 1.7 million saving in achieving Level 3 for LWH • Trust performance indicators • Use as lever with Trust to gain resources for maternity services

8. CNST Planning Group • Develop action plan including all criteria. • Designated persons and time scales for required action- takes longer than you think • Use scoring in ‘Summary of Standards’ to check on progress and areas of difficulty • Don’t overlook criteria from lower levels as need 90% in those • Regularly reassess.

9. Think Evidence • Use the guidance in the manual • Make sure every thing in each criterion is covered • Have evidence for each item of verification • Keep in separate file for each standard • Keep it up to date & review regularly

10. Key People • Training and postgraduate education leads • Audit department • Midwifery and directorate management • Clinical Risk Management MW • LW, clinic and ward managers • Complaints manager • Someone from neonatology and anaesthetics • Clerical help with minutes

11. Engagement- up ad down the organisation • Directorate management • Executives • Board • Consultants • All staff

12. Big ‘things’ at Level 2& 3 • Implement risk strategy • Lessons from incidents • Confidential enquiry lessons • Robust system for all test results • Antenatal risk assessment documented • Annual Skills Drills – all staff • Full risk assessment • Appropriate clinical staffing ( consultants and midwives) • Audit

13. Standard 1- Organisation • Risk management strategy • Philosophy, objectives, responsibility, coordination, accountability, implementation, author, review date. • Board minute that approved it. • Job descriptions of nominated lead(s) • Risk management (1.1.2) • Delivery Suite (1.1.4) • Use consultant job plans

14. Organisation • Risk management strategy distributed to all professional staff (1.2.1) • Evidence of implementation and annual review (1.2.2) • Original and revised strategies • Action plans • Minutes of meetings

15. S Standard 2 Learning from Experience : Learning from experience • Incident reporting (2.1.1). • Use list of triggers in manual. • Make sure all staff reporting. • Analysis, review, and actions (2.1.2) • Need to show for each area • Numbers and trends • Actions taken, changes needed.

16. Learning from experience • Strategic approach to incidents that might lead to a claim (2.2.1) • Use guidance in manual for guideline • Start early after incident • File of evidence, update regularly • Evidence of lessons learned and action arising from adverse incident reporting (2.2.2 ) • Changes in practice in response to complaints (2.2.3)

17. Standard 3 - Learning from experience • Considers and applies the recommendations made in the National Confidential Enquiries (2.2.4 ). Audit of service against these (2.3.1) • Action plans for each one (Don’t forget CISH & NCEPOD) • Audit showing changes in practice or rationale for not implementing recommendations • New policies • Minutes of meetings where discussed

18. Standard 3- Communication Patient information ( 3.1.1 & 3.2.1) • Alternatives, risks and benefits, consequences • Different formats and languages • P.I.G terms of reference and minutes • Labour Ward forum (3.1.5 ) • Terms of reference • Group members - 50% attendance • anaesthetist, neonatologist, junior MW & medical staff, consumer. • Minutes

19. Communication • System for test results( 3.2.2 & 3.3.1) • Guideline to cover this. • Patient information on screening. • System for ensuring tests done, reported , relayed and acted on. • Training • Uptake and detection rates (don’t forget neonatal screening)

20. Communication • At risk women (3.2.3) • Mental health guideline and screening process • Domestic violence • Documentation of these risks • Availability of interpreters • Follow up of non attendees

21. Communication • Emergency Caesarean Section (3.2.4) • Unit standard • Annual audit recommendations and action plan • Review of audit and remedial actions • System for early referral where fetal abnormalities have been identified (3.2.5) • Guideline/pathways

22. Standard 4 - Clinical Care • 27 clinical guidelines (4.1.1) • evidence based, dated, minutes of meeting where approved • Systematic approach to guideline development (4.2.1) • Policy, minutes of meetings, distribution & archiving old versions • Audit of guidelines at least 14/27 within 3 years (4.3.1)

23. Clinical Care • High Dependency care (4.1.3) • Guideline including lines of communication • Recovery (4.1.4) • Post op/recovery guideline • Training in monitoring, airway and resuscitation for MWs

24. Standard 5 - Induction training and competence • CTG training (5.1.3) • Need evidence of 6 monthly attendance • Formal study day • Informal- computer package, video, consultant DS sessions • Annual skills drill (5.2.1, 5.3.1) • Obstetric Emergency day covers: • CTG, CPR, Neonatal resuscitation, cord prolapse, breech, shoulder dystocia, massive haemorrhage • Ran at least monthly

25. Induction training and competence • Junior doctors competency (5.2.2) • Skills checklist based on RCOG log book. • Educational supervisors go through this at induction • Log book of supervised procedures

26. Standard 6- Health Records • Record keeping audits (6.1.2, 6.2.1, 6.3.1) • Audit tool • Must cover electronic records as well as paper • check reports and results and action plans are available. • Level 3 need to show improvement • Need evidence of changes cited in action plans

27. Health Records • These were previously level 2 now level 1 • Medical and midwifery records (6.1.3). • chronological order • all professional notes are filed together • Designated place for recording (6.1.4). • of hyper-sensitivity reactions • other information relevant to all healthcare professionals

28. Standard 7: Implementation of Clinical Risk Management • All clinical risk management systems are in place and operational (7.2.1). • Evidence of nominated lead playing an active role • Staff awareness of systems • Staff feed back, news letters, notice boards • Collaboration with audit, claims and complaints • Involvement of service users

29. Implementation of Clinical Risk Management • Multidisciplinary clinical risk assessment (7.2.2, 7.3.1) • Check tool covers guidance in manual for breadth, content, depth and action • Prioritisation of risk • Action plan, responsible persons • Board acceptance- need minutes • Progress on action points

30. Standard 8 - Staffing levels • Dedicated anaesthetic (8.1.2) and ODA cover (8.1.3) • check recommended levels are reflected in the rota, and the rota is clear. • Labour ward medical cover (8.2.1) • 40 hours dedicated consultant cover- job plans and timetables • Available out of hours within 30 minutes • Resident SpR

31. Staffing levels • Midwifery staffing (8.2.2, 8.3.1) • 1:1 • Birthrate plus • Contingency plans etc • Supervision of midwives(8.1.1, 8.2.3) • Action plan on LSA report • Evidence of monitoring of annual reviews

32. Summary • Good reasons for aiming high • Team approach especially with training • Attention to detail • Evidence is crucial- training and induction records • Keep reviewing your position • Don’t forget lower level criteria • Good luck