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

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Preparing for CNST Maternity Levels 1, 2 and 3
Experience of the Liverpool Womens Hospital

• Helen Scholefield
• Consultant Obstetrician Lead for Clinical Risk
  Management

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• 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

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Trust CNST Maternity Levels
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Why separate Maternity Standards
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Organisation with a Memory 2000

• Reduce risk in Obstetrics by 25 by 2005

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8 standards

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

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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

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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
• Dont overlook criteria from lower levels as need
  90 in those
• Regularly reassess.

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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

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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

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Engagement- up ad down the organisation

• Directorate management
• Executives
• Board
• Consultants
• All staff

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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

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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
• 
  
  
  
  
  
  

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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

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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.

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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)

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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 (Dont forget CISH
  NCEPOD)
• Audit showing changes in practice or rationale
  for not implementing recommendations
• New policies
• Minutes of meetings where discussed

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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

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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 (dont forget neonatal
  screening)

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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Staffing levels

• Midwifery staffing (8.2.2, 8.3.1)
• 11
• 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

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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
• Dont forget lower level criteria
• Good luck