MANIC Learning Diary 23.04.2018

Learning Diary:

The National Maternity and Neonatal Health
Safety Collaborative
@ UHCW

Supriya Bulchandani – Kara Marshall –
Consultant Obstetrician Group Manager
& Gynaecologist

Lorna Bass – Maternity Rose Blake –
Risk Manager Neonatal Matron

UHCW TEAM

• Maternal and neonatal health safety collaborative
team identified by the senior team in Womens &
Childrens.

Launch of the project
in London

Launch: Breakout Sessions

MANIC LOGO’s
Maternal and Neonatal Health

Improvement Collaborative

MANIC Logo

Meetings with Janine Lucking

(Improvement manager in the patient safety team at NHS
Improvement)

• 12/04/2017
• 18/07/2017 – Louise Stewart

• 04/09/2017
• 26/10/2017
• 13/11/2017 – Ann Abbassi
• 21/12/2017
• Scheduled… 07/02/2018 (Conference Call)

Off to Leeds… for a 3 day learning set

Leeds: Learning Set Day 1 Agenda

Leeds: Learning Set Day 2 Agenda

Leeds: Learning Set Day 3 Agenda

New Friends!

Networking with
other trusts on

Wave 1

Team Working with our Neighbours at
George Eliot….

Back at UHCW…

Awaiting improvement
tools!!!

Improvement Lead Team
Meeting

08/06/2017

• 6 actions in progress –
including this Manic

Newsletter to all maternity
and neonatal staff.



Staff Survey Cards

(double sided)

• Designed, printed and
displayed in clinical
areas.

Staff Survey Cards

• Staff informed via
newsletter.

Staff Survey: Survey Monkey

A survey monkey
was created to be
used alongside the

posters.

Staff engagement in
the work areas.

Designing the Poster



Final Poster

Newsletter to Staff.





Roaming Board

1st Box report

The National Maternity and Neonatal
Health Safety Collaborative
@ UHCW

The Grand Round Presentation
08.09.2017

Supriya Bulchandani Kara Marshall
Consultant Group Manager

Obstetrician & Rose Blake
Urogynaecologist Neonatal Matron

Lorna Bass
Maternity Risk

Manager

Executive Sponsor - Meghana Pandit

MBRRACE-UK

• Stillbirth rates fell to 4.7 per 1,000 total births in England in 2013

• The rate of extended perinatal mortality (EPMR) in the UK has fallen from 6.04 to
5.61 deaths per 1,000 total births between 2013 - 2015 for babies born at 24+0
weeks & onwards

• This fall is due to a reduction in the stillbirth rate, which
has fallen to 4.2 to 3.87 stillbirths per 1,000 total births (in 2015), in particular for
antepartum stillbirths of at least 32+0 weeks

• UK stillbirth rate continues to be among the highest of high income countries

• Rate - more than double that of the best performing nation - Iceland (1.3)

What is the Collaborative?

• National programme led by NHS Improvement

• Aims to reduce the rate of stillbirths, neonatal death and brain injuries occurring
during or soon after birth - 20% by 2020 (50% by 2030)

• Each Trust - Local Improvement Plan (LIP) to deliver this aim

• Safety Culture - at the heart of this initiative

National Roll Out of the Initiative

3 Waves over 3 Years
UHCW in Wave 1

3x3 day Action Learning events enabling us
to share & learn from other organisations
across the UK whilst developing our Local
Improvement Plans (LIP)

The Collaborative is Modelled on Four
Principles

Aim of the Programme Primary Drivers Secondary Drivers

1. Human 1.1 Build an infrastructure to support safety and improvement science by creating the conditions
Dimensions for continuous improvement

To improve Reduce the 2. Systems 1.2 Create the conditions for a safety culture
outcomes rate of and Process 1.3 Create a learning system
and reduce
unwarranted stillbirths, 3. Clinical 2.1 Develop a collaborative measurement strategy that measures improvement and
variation by neonatal Excellence demonstrates impact
providing a death and
safe, high 2.2 Learning from and designing reliable systems and processes within maternity services
brain 2.3 Design and implement highly reliable and effective pathways of care
quality injuries
healthcare occurring 3.1 Increasing the knowledge & learning from all causes of avoidable harm and examples of
experience during or excellence
soon after
for all birth by 3.2 Improve the proportion of smoke free pregnancies
women, 20% by 3.3 Improve the detection and management of diabetes in pregnancy
babies and 3.4 Improve the early recognition and management of deterioration of either mother or baby
families 2020
across during labour
maternity 3.5 Improve the detection and management of neonatal hypoglycaemia
care settings 3.6 Improve the optimisation and stabilisation of the very preterm infant
in England.
4.1 Work with Mothers and families to improve their experience of safer care
4. Person 4.2 Work with staff to improve the work environment to support staff to deliver safer care
Centred 4.3 Work effectively with local network and commissioning organisations to develop effective

local maternity systems

Staff Collaboration

•To inform the Driver Diagram & develop our Local Improvement Plan which
identifies the changes required by what measure & by when

Engagement Local Safety
Champions

Safety Honesty!
Huddles

•Staff engagement is key - We want to put into action what you say to us

The Daily Feedback

Daily Feedback – MATERNITY Results
What Went Well?

Teamwork

Good support
Adequate staffing

Providing a good patient experience
Providing safe care

Great staff

Good communication

Receiving positive feedback on performance 5 10 15 20 25 30 35 40
0

Daily Feedback – MATERNITY Results
What Could Be Better?

Low staffing levels
Work not completed / as expected

Lack of available kit
Stressful shifts

Clinics over running
New soft packs not fit for purpose
Difficult to provide adequate care
Difficulty providing meals for patients
Poor communication / follow up of results / care
Poor equipment maintenance / noisy cots / beds

Working extra hours for no pay
Not getting breaks

Men on ward inappropriately dressed
Moving staff to other areas
Babies arriving cold
Not feeling valued

0 2 4 6 8 10 12 14 16 18

Daily Feedback – NEONATAL Results
What Went Well?

Daily Feedback – NEONATAL Results
What Could Be Better?

Poor skill mix
Work not completed as planned / expected

Low staffing levels
Poor planning

Poor admin support
Poor leadership
012345678

The Staff Voting Poster & Survey Monkey

The Team on Rounds for Staff Engagement

Posters Collected from all Staff Areas

Tally: Yellow Dots

Team Evaluating Staff Votes

560 votes
placed in

total



Create the Conditions for a Safety Culture

Project Title: Improve the process for disseminating learning
through joint maternity & neonatal forums

• CAE forums
• Quality of Care
• Formulate joint obstetric & neonatal huddles



Design and Implement Highly Reliable and
Effective Pathways of Care

Project Title: Delivery of a standardised induction of labour
pathway

• Indications for induction
• Length of induction
• Low risk inductions