1. Victorian Maternity Record (VMR) Pilot – a Change Management project
6/04/2017
Victorian Maternity Record (VMR) Pilot – a Change Management project
Leanne Holmes
25th HIMAA National
“SEE- CHANGE” conference
Four Points by Sheraton Hotel
Geelong July 28th 2005
Today I would like to talk about the development and pilot of a hand held maternity record.
Please read the Conference proceedings for additional information about the rationale to this pilot and its long gestation.
In December 2003 Department of Human Services (DHS) awarded the Women and Children’s Program at Sunshine Hospital (Western Health) a two-year project grant to develop and pilot a handheld maternity record for use throughout Victoria.

2. 6/04/2017
The Victorian Maternity Record (VMR) project has two simple goals –
to inform clinicians and to engage women.
GPs and women involved in shared maternity care are expected to benefit.
GPs will have better access to information, test results and hospital management decisions.
Women will experience fewer incidents of duplicated tests, investigations and discussions.
With women carrying their own VMR they will become better informed of their well being during their pregnancy
While health services around Australia have developed handheld antenatal records, no one has yet developed a handheld maternity record that encompasses the complete care provided from maternity booking through to birth and hospital discharge.
Nor have women been encouraged to keep the original.
MISSION

3. project plan A comprehensive project plan was developed in 2004.
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Establish/Manage
Plan/ Document
Design
Consult
Pilot
Disseminate / Train M1 M4 M6
M11
M20
Secure host
Dec04
Write project plan
Apr – Aug 04
Initial design criteria written & approved
Apr 04
Methods approved
May – Aug 04
M14
Sites Agreed & Approved
Apr 04 – Nov 04
Communication Strategy Written & Approved
Feb 06 M2
Establish project team & management strategies
Mar – Aug 04
M12
Complete pre Pilot consultation
Jun - Dec 04
M15
Pilot methods agreed @ sites
Jun - Dec 04
M21 M7
Dissemination strategy developed & approved
Feb 06
Initial Design Options
May 04 M5
Progress Reports
Ongoing
M16
Pre Pilot
Nov - Dec 04
Final Draft
Dec 05
Pilot Record
Dec 04
EHR Plan
Feb 06 M8 M9
M10
M17 M3
Preliminary site visits
Feb 05
Establish Reference Group
May –Aug 04
A comprehensive project plan was developed in 2004.
The project plan is split into six phases:
Establish and manage the project
Plan and document the project
Design the record
Consult with stakeholders
Pilot the record
Disseminate findings and training
We are 2/3 through this ambitious two-year project:
There are two of us primarily employed on the project team in a part time capacity.
Jo Campbell has a background in sociology, research and change management and is the Project Co-ordinator
I offer the health information, technical IT and project management expertise.
Our main role, in collaboration with others, is to:
Design and develop the VMR record,
co ordinate the trial of the pilot in 7 pilot sites,
offer training and support and
undertake the final evaluation.
M18
M13
Pilot
Jan 05 – Dec 05
Consultation during Pilot
Feb 05 – Dec 05
M19
Survey/ process evaluation completed
Jun 05 – Feb 06
project plan

4. Consultation with women -Consumer Workshops
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Consultation with women -Consumer Workshops
Women carry it
Women read it
Women keep it
Consumer- friendly language
78% of participants agreed it would be useful to carry a hand held record
Consumer workshops
What was different about this project from the start, was the emphasis on the consumer – women. She is usually young and of childbearing age and is not sick. These women are not really “patients”, they are just having a baby.
It was important that women’s opinions were sought before initiating a hand held record. One of my roles in this project was to engage directly with women and co-ordinate and facilitate consumer workshops. Different from a HIM role!
In June and October 2004 consumer workshops were conducted. Women were invited to attend these workshops to:
Discuss their experience of pregnancy care
Discuss a new handheld record
Discuss the usefulness of an informative booklet on tests in pregnancy.
Conducting these workshops was quite a challenge and yet it was refreshing to receive useful feedback from women.
78% of women thought it would help if they carried a hand held maternity record. They said having a maternity record would help them to communicate better with doctors and midwives.

5. Using the Generic information booklet with the VMR
6/04/2017
Using the Generic information booklet with the VMR
Even non English speaking women thought including booklet about medical tests was useful
The four workshops included discussions with English, Sudanese, Vietnamese and Arabic speaking women. Interpreters were available to interpret the opinions and translate the feedback sheets completed by participants.
The workshop was run in conjunction with discussions on the introduction of a new generic information booklet, developed by the 3 Centre’s Collaboration, which was to accompany the VMR.
Language was not seen as a barrier for those where English is their second language.
By carrying the VMR women believed that it might empower them to be more responsible throughout their pregnancy. All women agreed that it was important to include written information about medical tests with the VMR.

6. Consultation with clinicians -Scenario workshop
6/04/2017
Consultation with clinicians -Scenario workshop
Clinicians test the VMR
Identify strengths and weaknesses
Hospital and GP will takes copies for their records
Similarly Consultation with clinicians was undertaken throughout the design phase.
On 24 November 2004, a mixture of 50 obstetricians, midwives, GPs and health information managers from around Victoria attended a scenario workshop.
The objective of the workshop :
test the draft VMR & identify strengths and weaknesses and ensure sites begin the pilot with a useful, robust draft
generate feedback from clinicians on the draft VMR as a generic tool to record and communicate clinical information across the maternity episode
create an opportunity for clinicians to learn and discuss the objectives, clinical practice and information management implications of the VMR Project
The participants were split into groups. A role playing exercise was undertaken where fictitious women with different maternity profiles presented. The groups were asked to document each profile and clinical picture using the VMR tool.
Each group discussed the format of the VMR and made suggestions for the final refinement of the VMR tool prior to final printing.

7. Carry Wallet Information booklet
6/04/2017
Carry Wallet
Throughout the initial planning period a range of design options were considered. A review of existing hand held records throughout Australia and overseas, assisted in the generation of two early designs.
In January 2005 the 7th and final version was accepted as the pilot tool.
Show VMR
Attached with a file fastener
Non-toxic plastic A5 size wallet.
Guide to tests and investigations booklet developed by the 3Ccentre’s collaboration inserted inside the wallet pocket.
Writing Guard
Information booklet

8. VMR Page 1-4 Women can write in the 1st four pages : Demographics
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VMR Page 1-4
Women can write in the 1st four pages :
Demographics
Appointment details
Birth preferences
The end result was a 15 page hand held Victorian Maternity Record (VMR).
The first 4 pages are provided for women to read and write
Demographic details
Appointment details
Birth Plan and Preferences .

9. VMR Instructions for clinician and women
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VMR Instructions for clinician and women
Women must consent to carry it
Frequently asked questions included
The Instructions page was developed to explain the correct use of the VMR.
Women must sign a consent to carry it
The VMR contains detailed instructions for the woman and clinician to read prior to commencement.
These instructions include frequently asked questions such as:
What if I don’t want to carry it?
I want to carry it but I am worried about privacy of certain information.
What if I forget it?
Is this the only record?
Is this the whole record?

10. Clinician notes p 5 - 14 Maternity History and Examination
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Clinician notes p
Maternity History and Examination
Tests and Investigations
Progress through pregnancy
Labour & Birth
Baby Summary
Discharge and Going Home
Glossary of clinical terms .
The contents of the VMR include provision to record the following :
Maternity History and Examination
Tests and Investigations
Progress through pregnancy – antenatal visits
Labour and Birth details
Baby Summary
Discharge and Going Home details and follow up.
It includes useful information and discussion checklists for women to view,
as well as space for clinicians to document the usual clinical notes.

11. Progress through pregnancy
6/04/2017
Progress through pregnancy
Giroform high quality carbonless paper
ISO 9001 compliant
NCR copies in triplicate
WOMEN KEEP THE ORIGINAL!
The VMR uses Giroform high quality carbonless paper.
It meets ISO 9001 standards.
Ten of the pages are in triplicate and designed to have the (NCR) copies removed at designated intervals throughout the pregnancy.
Each sites decides which copy they keep. Woman keeps the original.
The birth hospital and shared care GP remove the NCR copies from the VMR at regular intervals.
The 2nd and 3rd copies are printed in blue.

12. Labour & Birth Summary
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The VMR follows the woman's pregnancy through to labour and birth. A Labour and Birth Summary is designed in such a way so that woman can keep a copy of her birth details. It also can communicate more readily the outcomes of the birth and provide the clinician and woman with vital information to assist during their follow up.
The VMR is supplementary to hospital notes. For example: the partogram, Caesarean section clinical pathways, Operation and Anaesthetic records are still kept in the hospital medical record.
Clinicians will decide what they include in the VMR.

13. Baby summary Baby Summary
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Baby Summary
Copy for babies medical record is also provided

14. Going home
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Going Home
This includes domiciliary information and follow up details

15. Additional Notes Use as progress notes Pads of 50 in triplicate
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Additional Notes
Use as progress notes
antenatal in ER
post natal in ward
GP rooms
Pads of 50 in triplicate
Use writing guard
“Additional Notes” pads were also developed. They were to be used in much the same way we use progress notes. A cardboard writing guard was also included in the VMR kit to ensure handwriting did not bleed through the NCR copies.
Use as progress notes
antenatal in ER
post natal in ward
GP rooms
Pads of 50 in triplicate
Use writing guard

16. VMR poster Display on doctors/clinic waiting room walls
6/04/2017
VMR poster
Display on doctors/clinic waiting room walls
Reminder to women to bring their VMR
A poster was developed for promotion at each of the pilot sites. GP’s and hospitals are encouraged to display the poster in their waiting rooms.
The poster reinforces and reminds women to remember to bring the VMR to each visit.

17. 6/04/2017
pilot process
7 sites Sunshine, Mercy, Angliss, Mildura, Orbost, Kyneton, Seymour
1000+ health & other professionals
midwives, obstetricians, GPs, paediatricians, managers, health information, emergency staff, allied health, interpreters & translators, graphic designers, packaging experts, change management and group facilitation consultants, medico legal, policy/DHS/MSAC, project managers, IT experts, software designers, students, clinical educators, public relations, RANZCOG, ACMI, GPDV, consumer reps
5000+ women
Seven pilot sites currently trialling the VMR. The pilot was designed so that it can be tested with women throughout the 9 months duration of their pregnancy..
The seven pilot sites are:
Sunshine Hospital,
Mercy Hospital for Women,
The Angliss Hospital,
Mildura Base Hospital,
Orbost Regional Health,
Kyneton District Health Service and
Seymour District Memorial Hospital.
It is expected over 5000 women will participate in the pilot until Feb 2006.

18. Establish pilot management strategies Identify and act on issues
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Establish
Prepare
Begin
Monitor
Close
Select Pilot sites
Dec 04 P1 P4
Set aims and measures
Jan – Mar 05 P6
Collect data
Mar - Dec 04 P7
Process Evaluation
Feb 05 – Dec 05
P10
Introduce VMR
Feb - May 05 P2 P8
Survey staff
Dec 05 – Feb 06
P11
Establish pilot management strategies
Dec 04 - Feb 05
Identify and act on issues
Mar - Dec 04
Pilot plan P5
Design Processes
Jan – Feb 05; Ongoing
P12
Final
Recommendations
Apr05 - Feb 06 P9
Consult & inform
Feb 05 – Dec 05 P3
Pilot Plan
Each pilot site is provided with guidance in the implementation of the pilot although they are encouraged to innovate to find the most effective way the VMR can work in their organisation.
The pilot plan was split into five activities.
1 Establishment of the pilot site team.
Nomination of a pilot co-ordinator at each site was crucial.
Developing a communication strategy. This is perhaps the single most challenging aspect of the pilot project. Communication breakdowns can make or break the success of a pilot project.
2. Preparation of the pilot. This required the setting of aims and measures and designing processes.
Aims should target areas for improvement important to each organisation.
Sites also had to determine their recruitment strategy. Which women are they targeting - shared care only or those attending the Birthing Centre?
3. Begin the pilot by introducing the VMR. Pilot sites were encouraged to promote the introduction by having a launch or Go Live within their community. All 7 sites are now using VMR.
Schedule & timelines
Nov 04 - Feb 05

19. Process mapping- what stays & what goes?
6/04/2017
Process mapping- what stays & what goes?
Pre-pilot Map 1
prior to VMR
Pilot Map 2
changes after VMR
Post Pilot Map 3
final changes after using the VMR over time.
4. Monitoring the activities, identification of issues and collection of data. (This is where all sites are focussing their attention now)
Process mapping. Pilot sites have been asked to develop process maps to document their workflow processes from Maternity booking through to birth, discharge and record processing. This exercise is necessary so that organisations are able to track and measure the changes that have occurred throughout the pilot. Three process maps are to be developed.
Pre-pilot Map 1 - reflects workflow prior to commencement of VMR.
Pilot Map 2 – reflect after the implementation of the VMR
Post Pilot Map 3 - reflects the final changes made to workflow as a result of using the VMR over an extended period of time.
5. End of pilot, survey evaluation & final recommendations.
The pilot will end in February 2006 at which time a comprehensive evaluation of the pilot will be undertaken. Both consumers and staff will be asked to complete surveys as part of this evaluation process

20. 6/04/2017
Action Research
This Pilot is based on what is known as an “action research” improvement method.
The strength of action research is its responsiveness and the ability to turn unpromising beginnings into effective endings by converging on an appropriate outcome over time.
The VMR is encouraging pilots to innovate and change their current work practices
This Pilot is based on what is known as an “action research” improvement method.
Sites should audit and monitor the progress throughout the pilot. Since this is an Action Research project, there is no reason why pilot sites cannot tweak the process as they go until the VMR tool works effectively in their organisation.
The strength of action research is its responsiveness and the ability to turn unpromising beginnings into effective endings by converging on an appropriate outcome over time.
The VMR is encouraging pilots to innovate and change their current work practices

21. Plan, Do, Study and Act cycle (PDSA)
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Plan, Do, Study and Act cycle (PDSA)
The pilot sites are encouraged to apply PDSA cycles to their processes to assist them with learning and reflection. People identify issues and actions.
Site teams respond with a plan of action (PLAN).
The plan is actioned for a period of time (DO).
This may involve measuring or observing. They study and reflect on the effects (STUDY).
They act again. (ACT).
PDSA cycles are built around issues identified from the ‘floor’, and from the routine measurement of progress towards aims.
PDSA Cycles & Action Research
To do this they are encouraged to apply PDSA cycles to their processes to assist them with learning and reflection. Pilot teams should identify issues and actions
Coordinators/site teams respond with a plan of action (PLAN).
The plan is actioned for a period of time (DO).
This may involve measuring or observing. They study and reflect on the effects (STUDY).
They act again. (ACT).
PDSA cycles are built around issues identified from the ‘floor’, and from the routine measurement of progress towards aims.
By applying the PDSA cycle we have an opportunity to try different ways to make it work… without the feeling of doom and failure.
This allows a lot of scope to tweak the process until it works..

22. 6/04/2017
Example of an issue: “The VMR is taking longer to complete” could mean???
It takes longer but it is worth it.
Consultations were too short prior to the VMR
Documentation was lacking previously
It takes longer because people are still getting used to it. When familiar it will take less time.
It takes longer because women are asking questions
It takes longer because the midwives are repeating what the doctor/GP has done.
POSSIBLE SOLUTION: Change to appointment times
Here is a typical example of what we are hearing at present from a few pilot sites:
The VMR is taking longer to complete. This could mean:
It takes longer but it is worth it.
Consultations were too short prior to the VMR
Documentation was lacking previously
It takes longer because people are still getting used to it. When familiar it will take less time.
It takes longer because women are asking questions
It takes longer because the midwives are repeating what the doctor/GP has done.
Possible solution Review appointment times

23. 6/04/2017
Change
“Change is complicated by the fact that organizations are social systems whose participants have identities, relationships, communities, routines, emotions and differentiated powers. Thus managers must be alert to how a change will conflict with existing social systems and routines.”
Harvard Business Essentials, Managing Change and Transition 2003
Certainly the VMR project does require a change in our thinking and our actions. It is a pilot which provides an opportunity to innovate, in a health climate which is not always innovative.
“Change is complicated by the fact that organizations are social systems whose participants have identities, relationships, communities, routines, emotions and differentiated powers.
Thus managers must be alert to how a change will conflict with existing social systems and routines.”

24. “The primary difficulty with change…
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“The primary difficulty with change…
is that it is 10% logical/physical and 90% social/emotional.
No matter how much we try to justify our proposed change with logic...or resources, change is tough because it is primarily cultural in nature.
Cultures are primarily emotional, not logical.
Those of us who value logic like to explain our preferences from a sensible framework but when it all boils down, emotion runs deep.”
“The primary difficulty with change…is that it is 10% logical / physical and 90% social / emotional. No matter how much we try to justify our proposed change with logic...or resources, change is tough because it is primarily cultural in nature.
Cultures are primarily emotional, not logical. Those of us who value logic like to explain our preferences from a sensible framework but when it all boils down, emotion runs deep.”[1]
[1] 3Centres Collaboration workshop – Leading Change November 2002.

25. Future impact on Health Information Services?
6/04/2017
Future impact on Health Information Services?
Women carry VMR 
reduction in clinic preparation time
Women keep VMR
reduction in filing space
Women read their VMR
less FOI requests
Standard forms design
(Statewide)
reduction in forms design responsibilities for HIM’s
NCR Copies kept in medical record
need to review medico legal legislation
Women carry VMR lead to reduction in clinic preparation time
Women keep their VMR lead to reduction in filing space
Women read their VMR lead to less FOI requests
Standard forms design lead to Reduction in forms design responsibilities for HIM’s
NCR Copies kept in medical record lead to review medico legal legislation

26. Leading Change with the VMR
6/04/2017
Leading Change with the VMR
THE VMR project is about leading change
The VMR project provides an opportunity to change and innovate in the workplace
The VMR project identifies staff resistance but also staff readiness
The VMR project provides an opportunity for us to step back and look at the way we do things!
The VMR has the promise of new vision, streamlining structures and provides a catalyse for people towards a common goal – provision of better health care for our women.
There is no doubt that the VMR pilot project is about leading change.
The VMR project provides organisations with an opportunity to change and innovate in their workplace.
It will identify staff resistance but also staff readiness.
The VMR project provides an opportunity to step back and look at the way we do things!
The VMR has the promise of new vision, streamlining structures and provides a catalyse for people towards a common goal –
provision of better health care for our women.

27. The VMR has changed my thinking!
6/04/2017
The VMR has changed my thinking!
Initially I thought :
that this was a forms design project – WRONG!
that only an electronic health record would solve all our paper record problems – WRONG!
Women felt empowered in their decision making when having a baby – WRONG!
I now know:
there is a lack of CONSISTENT information available for women about maternity care
HIM’s should review their role as forms design experts and custodians of medical records.
HIM’s should embrace the notion that there is a place for personal hand held records in the future!
change requires greater consideration of the social influences within ourselves and our organisation rather than just the logical influences.
MY personal experience
Initially I thought :
that this was forms design project – WRONG!
that only the electronic health record would solve all our paper record problems – WRONG!
Women felt empowered in their decision making when having a baby – WRONG!
I now know:
there is a lack of CONSISTENT information available for women about maternity care
HIM’s should review their role as forms design experts and custodians of medical records.
HIM’s should embrace the notion that there is a place for personal hand held records in the future!
Change requires great consideration of the social influences within ourselves and our organisation rather than just the logical influences.

28. Evaluation and findings
This pilot is well underway across 7 sites.
1,500 women are carrying the VMR so far.
95% of woman are consenting to carry it
No lost records were reported in May or June.
A final evaluation will be undertaken in February 2006.
Only after feedback is received from all consumers and staff will a decision be made about whether to implement state-wide.
Watch this space!!

29. Thank you: Jo Campbell (03) 8345 0430 jo.campbell@wh.org.au
Leanne Holmes (03)