NHSLA DNV Launch Seminar CNST Standards

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NHSLA/ DNV Launch Seminar CNST Standards

• The Relevance of the CNST Maternity Standards for
  the RCOG
• Sabaratnam Arulkumaran
• President
• 18th and 19th March 2009

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Adequate Capacity Adequate, well trained and
experienced Staff Educational courses
Training Good communication Team
work Guidelines for all staff on
intranet Patient complaints and Feedback Good
Risk Management gt feedback to improve
services Audit of Practice and Complications
(e.g. Near miss)
Problem?

Speed limit - Failure of brakes Untrained
driver Driver slept New territory Faulty/new
tracks Faulty/new signals No speed check





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RISK MANAGEMENT ROOT CAUSE ANALYSIS SYSTEM FAILURE
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CLINICAL GOVERNANCEPrevent adverse outcome -7
pillars

• Service accreditation
• Revalidation of personal
• Evidence based Guidelines
• Audit
• Education and
• training / CPD
• Patients complaints
• Clinical risk management

Safety Quality by CLINICAL GOVERNANCE A system
of continually upgrading /enhancing service
standards/care Learning from experience An
institution with memory
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CLINICAL GOVERNANCE
Professional Revalidation
Accreditation of Services
EB Guidelines Education Training Audit
Patients Complaints
Clinical Risk Management
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CNST - 5 StandardsTen Criteria Rationale
provided

• Standard 1 - Organisation
• Risk Management (Organisation)
• Risk Management (People)
• Staffing levels (Midwifery Nursing staff)
• Staffing levels (Obstetricians)
• Staffing levels (Anaesthetists Assistants)
• Guidelines
• Maternity Health Records
• Incidents, complaints Claims
• Training needs analysis
• Skills/ Drills

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Evidence for a consultant-based delivery suite
service fetal distress can happen at any time.
But serious morbidity/ mortality in the absence
of senior staff
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CNST - 5 StandardsTen Criteria Rationale
provided

• Standard 2 - Clinical Care
• Care of Women in labour
• Auscultation
• Continuos electronic fetal monitoring
• Fetal blood sampling
• Use of oxytocin
• Caesarean Section
• Recovery
• Severely ill pregnant women
• High dependency care
• Vaginal birth after Caesarean section

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6 out of 10 cases Lack of Consultant
Obstetricians input - expansion is needed to
improve safety, quality, satisfaction training
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CMOs report - 2007
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CMOs report 2007
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Clinical Governance - NHSLA and CNST
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CNST - 5 StandardsTen Criteria Rationale
provided

• Standard 3 - High Risk Conditions
• Severe Pre-eclampsia
• Operative vaginal delivery
• Bladder care
• Perineal Trauma
• Shoulder dystocia
• Obstetric Haemorrhage
• Venous thrombo-embolism
• Pre-existing Diabetes
• Obesity

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CEMD 2003-05MMR 13/ 100,000

• 10x more likely to die if unemployed
• Most deprived 5x more likely to die
• 52 obese at booking
• 17 had inadequate antenatal care
• 30 of children whose mothers died were in care
• Increase in indirect causes

50-60 SUB-OPTIMAL CARE
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Direct maternal mortality 1952-2005(rate per
million maternities)
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Direct and indirect maternal mortality
1987-2005(rate per 100,000 maternities)
Direct
Indirect
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8
7.8
7
6.4
6.1
6
6.1
6.1
5.5
5.3
5
5
4.3
4
3.9
3.7
3
2
1
0
'87
'90
'93
'96
'99
'02
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Direct and indirect maternal mortality
2000-2005(rate per 100,000 maternities)
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Why do mothers die? substandard care (direct
deaths)
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Rates of severe maternal morbidity
Near missdeath ratio, 561 (triennium) SPCERH
2007
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CommunicationWho was involved in hands-on
care?(N 512)
600
5
73
2
1
3
500
60
400
36
8
300
200
100
0
Obs.
Obs. SR
Obs. Reg
Obs. SHO
Anaes.
Sen. M.W.
Jun. M.W.
Consultant
84
98
98
98
99
100
71
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Unfamiliarity with the task - No supervision
Future gt Adequate supervision gt proper
assessment (OSATS) gt Safety
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Morbidity Mortality increases without direct
care supervision

• Remote surveillance may lead to more morbidity

• Immediate attendance by senior would reduce
  morbidity
• Consultant Presence would promote more normal
  deliveries - improve quality and safety
• Analogy Pilot Trainee pilot maternity
  services most times staffed by trainee doctor
• TRAINING CTG e-learning tool free for NHS
  staff

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Proposed Obstetric Staffing Targets
(2007-2010)(Adapted from The Future Role of the
Consultant 2005)
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Responsibility of Consultant on Call(RCOG advice
2009)

• Labour ward duties (safer childbirth)
• Must attend
• Major Post Partum Haemorrhage
• Eclamptic fit
• Collapsed patient
• Major placenta praevia
• Return to theatre - Laparotomy
• When trainee asks for it
• Be present (depending upon trainees experience)
• Trial of instrumental delivery/2nd stage C/S
• Twins/preterm labour C/S / vaginal breech
  delivery
• C/S at full dilatation/ for Transverse lie/ BMI
  gt40

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CNST - 5 StandardsTen Criteria Rationale
provided

• Standard 4 - Communication
• Booking appointments
• Missed appointments
• Clinical Risk assessment (Antenatal)
• Patient information Discussion
• Maternal Antenatal Screening Tests
• Mental Health
• Clinical Risk Assessment (Labour)
• Handover (Onsite)
• Maternal Transfer
• Admission to Emergency

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CNST - 5 StandardsTen Criteria Rationale
provided

• Standard 5 - Postnatal Newborn care
• Referral when a Fetal Abnormality is detected
• Resuscitation
• Admission to Neonatal Unit
• Immediate care of the Newborn
• Newborn feeding
• Newborn security
• Examination of the Newborn
• Support for Parents
• Postnatal Care Planning
• Postnatal Information

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Standards in Safer Child Birth, Maternity Care
Gynaecology Quality Metrics
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Maternity Standards - 30

• Prenatal (2)
• Antenatal (9)
• Intrapartum
• Postnatal (8)
• Generic (10)

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Preconception

• 1 Looking forward to pregnancy
• 2 Pre-pregnancy care for women with existing
  medical conditions or significant family or
  obstetric history

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Antenatal Standards
3 Access to maternity care 4 Early Pregnancy
Services 5 Maternity booking and planning of
care 6 Pre-existing medical conditions in
pregnancy 7 Women with social needs 8
Pre-existing and developing mental health
conditions in pregnancy 9 Antenatal
Screening 10 Routine Antenatal Care 11 Pregnancy
related conditions
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Intrapartum and Postnatal Care
12 Intrapartum Care 13 Neonatal care and
assessment 14 Postnatal assessment and care of
the mother 15 Supporting infant feeding 16 Care
of babies requiring additional support 17 Care
of babies born prematurely 18 Promotion of
healthy parent-infant relationships 19
Transition to parenthood 20 Supporting families
who experience bereavement, pregnancy loss,
stillbirth, or early neonatal death
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Generic Standards
21 Choice and appropriate care 22
Communication 23 Training and professional
competence 24 Documentation and
confidentiality 25 Clinical Governance 26
Development, implementation and review of local
maternity services strategy 27 Maternity and
Neonatal Networks 28 Child protection and
safeguarding babies 29 Infection Prevention and
Control 30 Staffing
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DESIGN OF SERVICES SHOULD DELIVER CARE TO
FULFILL STANDARDS STANDARDS IN THE DOCUMENTS
WORK WITH NICE TO FORMULATE QUALITY METRICS BEST
QUALITY SAFE CARE MONITORED BY MATERNITY
GYNAECOLOGY DASH BOARD QUALITY METRICS BASED
ON AUDITABLE STANDARDS PRODUCED BY NICE
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Performance Governance Score Card Maternity
Dashboard

• Designed by Prof. Arulkumaran Team Northwick
  Park
• Recommended by CMOs Report
• Looks at Activity, Staffing, Clinical Risk
  indicators, User feedback (e.g. complaints)

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Ensuring high quality safe care. Tool for
Commissioners, Providers, Consumers and
Regulators
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Implementation of the Standards should help to
achieve a World Class Clinical Service

• Fairequally available to all
• PersonalisedTailored to the needs and wants of
  each individual
• EffectiveFocussed on delivering outcomes the
  best in the world
• SafeGiving patients and public the confidence
  they need in the care they receive.
• AmbitiousResponsive to the aspirations of the
  patients and the public
• Shared vision (Darzi 2007)

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Staffing Issues

• Role of Post CCT (not holding consultant
  contract)
• El C/S op list
• Gynae on call duties
• Recruitment issues funding issues as labour
  ward duties are not a top priority

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Issues Identified

• Labour Ward Consultant Responsibility
• Principle Acute obstetrics and gynaecology
  should take priority
• Prospective Cover for Annual Leave (compliance
  demonstrated)
• Built in rota and job plan
• No other fixed commitments especially operating
  list
• Arrangements will vary according to size of unit
• Adequate workforce calculations (esp. PAs for
  weekend on site work)
• Post CCT as part of solution

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A Model for Consultant ObstetricianPresence in a
Medium Sized Unit (4000 births)
Only one member of team can be on leave Post on
call morning session is an SPA (12
basis) (Ref Safer Childbirth 2007)
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Issues Identified

• Evidence of unit policy
• Short Term Sickness
• Ad hoc arrangement
• Policy in place
• There should be someone who can physically do the
  ward rounds and be available when required
• Long Term Sickness
• Long term sickness should be covered formally

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Issues Identified

• 
  Business Plan
• Unit gt2500
• Direction of travel ? 60 hrs cover 98 hours for
  gt6000
• There should be weekend cover in place for labour
  ward rounds
• Prospective cover for annual/study leave
• Unit lt2500
• Direction of travel ? 40 hrs cover
• When on call ?am? rounds elective C/S list
• Pm session could be an admin PA/SPA
• Variables
• Complexity of case load
• Geographical isolation

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Issues Identified
El C/S list On call consultant (lt2500) or 2nd on
call consultant (gt 6000) (depending upon the
intensity of work, level of junior support, and
acute gynaecology workload) Gynaecological
Emergencies Consultant on call for labour
ward or 2nd on call team only for gynae
units Variable Possibility for very large
units at present
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Implementation of Safer Childbirth Targets

• Flexibility is the key
• Will need slippage agree
• Not enough trained CCT holders
• WTD solutions are being sought
• Recent economic downturn
• Recruitment cycle may take up to 6 months
• Contingency plans to address on-going shortfall,
  if any
• Contract issues esp. for 24 hr consultant
  presence (remuneration, job planning, time off
  post on all)

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Service Reconfiguration Debate and Future
Staffing Levels (Business Plan)

• Issue
• Planned changes agreed or not?
• Should it affect recruitment?
• Solutions
• How to provide current service?
• assess future needs!
• Scenario
• Unit size after reconfiguration gt4000 or gt6000
• Recruitment should take account of future needs
  (98 hrs/168 hrs cover)

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Implementing Safer Childbirth RecommendationsJuni
or Staffing Levels

• Constraints especially for units lt2500
• Possible reduction in training numbers
• Alternative solutions ? consultant delivered
  service
• Large units (ST6-7)
• There should be a clearly defined policy within
  the unit for delegation of responsibility

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Key Message

• A clearly defined business plan to address
  staffing short falls- end points
• Annual audit of Medical and Midwifery staffing
  levels in the unit
• Contingency plans for sickness absence
• Increased work load challenges supported by the
  use of Maternity Dash Board
• Evidence of consultant involvement in the care of
  high risk patients in labour

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Maternity ServicesWorking together

Excellent, Safe, compassionate friendly care
Quality Standards - Leadership and Team
work