An appraisal of the East of England ‘sixty supportive steps to safety’ tool

Maternity care is particularly susceptible to risk and, in England, the safety of maternity services has been the subject of recent enquiries. The Ockenden (2022) report on maternity services at the Shrewsbury and Telford Hospital NHS Trust was published in March 2022, followed by the Kirkup (2022) independent report of maternity and neonatal services in East Kent in October. Both reports indicated that the pace of change to meet maternity safety regulations, and ensure sustained safe maternity and neonatal care, needs to be accelerated.

These national reports identified that a poor safety culture can lead to poor outcomes, having a devastating impact on women, pregnant people, babies and families. It also impacts the wellbeing of staff who provide care, which can potentially affect individual and/or team performance, and can lead to increased sickness absence, further exacerbating the safety issue.

The national Better Births report (NHS England, 2016) set out an ambition to reduce the rates of stillbirth, neonatal death, maternal death and brain injury in babies, that occur during or soon after birth, by 50% by 2025. Although good progress has been made towards this goal, further work is needed. As of January 2020, 38% of maternity services were rated ‘requires improvement’ by the Care Quality Commission (2020) in the safety domain. Services that receive this rating are entered onto the national Maternity Safety Support Programme, indicating that they require additional support.

In May 2021, the East of England had the most maternity units enrolled in the NHS England National Maternity Safety Support Programme, with six out of 13 trusts and nine out of 18 maternity units enrolled. The regional maternity team's ambition was to develop and implement a tool to improve safe care, subsequently titled the ‘sixty supportive steps to safety’, in all maternity units, with completion of the tool intended to act as an early warning and proactively identify any areas of concern. This would enable trusts to implement resources, interventions and improvements before serious issues developed and affected safety in the maternity unit. The aim was to manage risk and prevent enforcement notices being issued following a Care Quality Commission regulatory visit.

Methods

The regional maternity team co-produced the sixty supportive steps to safety tool, alongside a maternity service user representative, the local maternity and neonatal system (involved with providing, supporting and commissioning maternity care) and heads and directors of midwifery. The approach, timeline and dissemination of the results are shown in Table 1.

The tool focused on safety and included, but was not limited to, evaluating leadership, governance, training, culture operational practices and record keeping. The tool's questions were based on national best practice documents and regulation to improve safety outcomes in maternity services, such as the Health and Social Care Act 2008, Regulated Activities Regulations 2015, the Maternity Incentive Scheme (NHS Resolution, 2021) and the National Institute for Health and Care Excellence (2015, 2017) guidelines for maternity services. Examples of the questions include:

• Are audits taking place to gain assurance that the saving babies’ lives care bundle (v2) (NHS England, 2019) is being implemented and there is compliance?
• Are there obstetric and maternity champions? Do they meet with the board safety champion bi-monthly and take minutes and action log?
• Do reviews of incidents and audits include ethnicity and how are the needs of ethnic minority service users addressed?
• Are women rag rated in triage and seen in timeframes?
• Do staff have the opportunity to debrief when things have gone well and when incidents have occurred that could have been managed differently and had a better outcome?
• When red flags are raised on the acuity tool, are they responded to appropriately?
• How are women's voices heard, listened to and actioned?

The regional maternity team offered all 18 maternity units in the East of England a visit to complete the tool. A pre-visit meeting was also offered, to answer any questions prior to the support visit. During the visit, the regional team met with the senior team (including the head or director of midwifery, the clinical lead and the general manager of the maternity service), governance and training teams. In addition, they spent time and spoke with staff in the labour ward, antenatal and postnatal wards, triage and antenatal assessment unit. Immediate verbal feedback was given to the senior team at the end of the visit, to enable celebration of good practice and focus on areas raised as concerns.

Subsequently, a short report was sent to each trust, to outline the results of the visit, identify good practices and focus on areas of care/practice that needed improvement to meet safety regulations and ensure a positive service user experience. The report was also shared with the local maternity and neonatal system, to enable them to benchmark and share practices and learning in the system.

Using the information from the visits, a directory of good practice was compiled and shared with all trusts, facilitating regional shared learning. The visits also identified areas where regional quality improvement project work could be initiated, including improvement of triage services, transitional care, community services and elective caesarean pathways.

Outcomes

The feedback from the visits was used as part of each maternity unit's improvement plans, in collaboration with support from the local maternity and neonatal system and the Maternity Safety Support Programme improvement advisors. After further regulatory inspections, one trust improved their rating to the point where they were able to exit the programme, meaning that the trust had made significant progress with the required improvements. This trust receives continued oversight and support from the regional maternity team.

Four trusts had improvements noted and three were due to produce sustainability plans to exit the programme in the coming months. Inspections were carried out at trusts where improvements based on feedback from the regional visits were made at pace, with one demonstrating no change in ratings and one receiving an improved rating.

The visits enhanced communication and improved transparency between maternity units and the regional maternity team. These stronger relationships have enabled early support from the regional team and enhanced collaborative system working. Maternity units were provided with the opportunity to recognise ‘what good looks like’ and escalate concerns appropriately to improve safety.

When developing the sixty supportive steps to safety tool, co-production between the Maternity Neonatal Voice Partnership chairs (service users from neonatal and maternity service who have lived experiences) and maternity services was included in the framework, in order to ensure that the service user voice was heard. Following the regional team visits, maternity units have made this a priority.

One section of the tool was a records review. This highlighted that the efficiency of trust's digital systems varied, and some were extremely difficult for staff to navigate and extract the required data. In these cases, follow up meetings were arranged to enable the data to be sourced and shared.

Feedback on the visits

Following the visits, the regional team requested feedback from the head/director of midwifery to enable the team to develop and enhance the visits. The majority of the feedback was positive, with support noted from senior managers, including chief executives, chief nurses and heads/directors of midwifery. Some midwives reported positively on the visits; however, two specialist teams (out of the 18 sites visited) found the questions asked to be quite intense. The regional team offered apologies and have adapted their approach to be more conversational when meeting specialist teams.

Summary

There has been progress in improving maternity safety in the East of England. The concerns that have been identified in the region are not new to maternity services To enable prompt change to address the areas of concern efficiently, there needed to be focus in areas that have been described in external reviews of maternity services (Kirkup, 2022; Ockenden, 2022). These areas were:

• Strong effective leadership
• Safe staffing
• Implementation of maternity continuity of carer, to deliver more personalised care
• Good governance
• Strong respectful culture and teamwork
• Effective support from system partners
• Improving maternity equity and engagement
• Providing a positive working environment for staff and promoting supportive, open cultures that help staff do their job to the best of their ability
• Continuing to learn from women/birthing people who use the services
• Maternity and Neonatal Voices Partnership participation, adequate resources and true co-production, involving service users in the design of maternity services from the beginning of a project.

Where areas of deviation from safety standards are identified, there needs to be prompt action to meet standards, in order to prevent regulatory enforcement.

Regional support initiatives

Several initiatives have been implemented, following the feedback from the regional team visits. Post-visit meetings have been offered at the maternity units, if required, and national guidance has been shared among the trusts. Support forums have been established, and two webinars have been instigated, one of which focuses on ‘celebrating good practice’ and one on ‘world safety day’.

A risk governance forum has been launched, with the aim of highlighting and sharing ‘what good looks like’, to improve structures, processes and consistency in the region. A quality improvement project is in progress to improve triage in maternity, and the regional NHS England divert policy has been reviewed, enhanced and updated. An operations pressure escalation level rating has been designed for maternity, and an action template for diverts has been produced.

The exception report template for right place of birth has been improved. Touch point meetings with Band 7s and matrons have been facilitated. In order to share good practice, signposting to units with good processes in place has been established, and there has been engagement and support from the regional medical advisor/lead obstetrician.

Limitations

There were some limitations to carrying out the visits and completing the tool. A few trusts were not digital, meaning that paper records needed to be reviewed, which was time consuming. Additionally, staff were not always available to meet as a result of operational activity (although this was mitigated by holding a meeting after the visit).

Dissemination of results

The feedback from all maternity units in the East of England was reviewed, with a thematic report being written and a PowerPoint presentation being developed. This was presented to:

• The NHS England East of England heads/directors of midwifery meeting
• The East of England risk governance forum
• The East of England local maternity and neonatal system project management office meeting
• The regional perinatal quality oversight group
• The regional Maternity Programme board
• The regional quality group.

Presenting at these meetings enabled attendees to contribute their thoughts, promoting positive discussions and debate that increased awareness of the safety agenda in the region. The tool, report and presentation are held internally by the East of England team and are not publicly available.

The work has also been recognised in the East of England, with the regional team being awarded East STAR's Award ‘team winner’ and the lead for the tool being awarded ‘individual runner up’ in April 2022. During a routine national to region oversight meeting, the Chief Nursing Officer for England was present and the tool was commended. A poster has been developed to enable further promotion of the tool, which is also held internally by the East of England team.

Conclusions

The sixty supportive steps to safety tool proved to be invaluable in triangulating evidence and assurance to ascertain safety concerns. Not all trusts and local maternity and neonatal systems had identified issues through previous self-assessments. The regional team were visible, supportive and proactive, which forged stronger, trusting relationships between the maternity senior leadership team and the regional team, which has also improved communication and transparency.

The regional team were able to develop bespoke support for maternity units’ individual needs and inform regional quality improvement projects.

Executive engagement, resources, the workforce, culture and compassionate leadership all influenced the pace that trusts were able to make improvements. Those that made improvements at pace found that, following regulatory visits, their ratings remain the same or have improved.

Key points

• The ‘sixty supportive steps to safety’ tool focuses conversations with frontline staff, enabling identification of operational safety concerns, where support is required and opportunities for learning, as part of continuous quality improvement.
• The tool was designed to allow trusts to identify where maternity practices required further resources or improvement to improve safety outcomes.
• It also provides an external lens and framework to highlight to senior leadership and executive board teams areas of excellence in practice and challenges in maternity and neonatal services.
• The tool enables maternity services to provide internal assurance to trust boards and external assurance to the local maternity and neonatal system and integrated care boards, in line with their statutory responsibilities.
• A critical success factor for the tool was to highlight where services should be resourced appropriately with dedicated funded posts.
• The tool was undertaken by independent practitioners in collaboration with maternity staff, including service user representatives.

CPD reflective questions

• What national policies and strategies are available to support clinical organisations to prioritise safety in maternity services?
• Who might be impacted by poor outcomes and require support?
• How is safety prioritised in your maternity unit?
• Where can you escalate safety concerns?