Audit of services can highlight areas of practice ripe for improvement. This was the case for obstetric anal sphincter injury (OASI), when a large-scale review showed an increase in occurrence for primigravid vaginal births (Gurol-Urganci et al, 2013). OASI has long term physical, psychological and social implications for affected women. It is life-changing, and not in a good way.
As a result, the Royal College of Midwives (RCM), Royal College of Obstetricians and Gynaecologists (RCOG), and the London School of Hygiene and Tropical Medicine developed a care bundle, which is a set of evidence-based interventions that, when implemented together, can improve outcomes. The OASI care bundle was piloted in two units to ensure that it was acceptable and feasible for clinicians. Following the pilot, funding was obtained from The Health Foundation to scale up implementation to 16 units (Bidwell et al, 2018).
The experiences of the participating units in instigating staff training and implementing the care bundle has highlighted the factors behind changing practice. Many of these will not be a surprise, but overcoming obstacles is vital to improving care. This column will look at six of these key factors.
Getting senior buy-in
It is vital to have visible support from senior management. Without it, many of the other important factors will not be in place. Senior buy-in is also essential to encourage protected time, which supports planning, monitoring and assisting those who find change difficult. Support in gathering evidence to support the change, including the wider evidence base, the local data, and the proposed outcomes is of key importance. It is also necessary to demonstrate the value of service improvement to the organisation and how it aligns with its wider aims.
Involving women
Supporting women to understand what the project is trying to do, what might be their risk factors and what role they can play in project implementation is important. Women can be drivers of change, but only if they know about the issue. The OASI improvement project has placed women at the heart of all activities and found that many are unaware of perineal trauma before birth.
Data
Information systems are needed to collect and analyse data, highlight that there is a problem, demonstrate the full nature of it and give feedback on the effects of all the interventions on outcomes. How good is your system? Does it enable you to access the data that you need? Can it be interrogated effectively?
Data need to be reviewed and interrogated on a regular basis. Units need to compare themselves with their neighbours and with units of similar type, and all care providers need to know and understand the key statistics about their unit. Analyses such as those by MBRRACE and the National Maternity and Perinatal Audit can assist in comparisons and identifying outliers.
Time for training
In today's over stretched maternity units, it is hard to find time for training. In studying how the OASI bundle was implemented, Bidwell et al (2018) found that there was no protected time, and this was a weakness. Without protected time, staff fall back on an ad-hoc approach, making it harder to ensure that there is equal access to training for all staff. It is also important that staff train together in ways that mirror real-life clinical situations.
Establishing champions
For any successful change, there needs to be people who promote and support it, enthuse others and provide feedback on progress. Because of the nature of the scaling-up project, there was no protected time for the champions during the OASI pilot. It is therefore vital that staff are regularly reminded about the initiative, the reasons behind it and the progress towards overall service improvement.
Team work
The final criterion for success is multidisciplinary working. This project was endorsed by both the RCM and RCOG, and has demonstrated the importance of joint working at all levels. Maternity care is a team effort, and so mutual respect, shared understandings and being open to new ideas are vital components.
Any service improvement needs detailed planning, widespread buy-in and time. Are you ready for change?