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) –A ction 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