Safety and Quality in Maternity Care Denise Boulter Midwife Consultant Public Health Agency

How safe is the health service?

How Hazardous Is Health Care? (Leape)

How Hazardous is Maternity Care 25,000 births Perinatal mortality lowest for 10 years Maternal death very uncommon However!!!!! Approximately 20 Serious Adverse Incidents reported Over 150 Complaints regarding maternity services 2012 NHS compensation bill exceeded £1 billion pounds 20% all claims are maternity 49% payout is for maternity

Public Health Agency Functions Health Protection surveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘flu Health Improvement Inequalities; public awareness; local interventions; partnerships; user involvement Commissioning & Screening Regional & local commissioning; public health priorities; wider influence; screening services Research & Development

PHA Commissioning Role Provide high quality independent professional and public health advice to support commissioning Lead on commissioning and service improvement of agreed areas of work Regional Board Must consult PHA and have due regard for advice or information provided Must not publish a commissioning plan without PHA approval LCGs Legislation requires LCGs to work in collaboration with PHA

“New Rules” for Health Care following Mid Staff Safety as a system property Need for transparency and effective reporting – information a tool rather than a trial. Test the systems and the staff More rapid response when things go wrong Tracking and providing feedback about adverse events Increased Cooperation

Issues There are serious problems in quality Between the health care we have and the care we could have, lies not just a gap but a chasm. The problems come from poor systems…not bad people The question is why have we not sorted it to date? We can fix it… but it will require changes

Ingredients Practice Evidence based Care Pathways Consistent processes Education & training People Person Centred Service Safety Forum Support and challenge Education and training

People You are the key ingredient in making patients safe. What can I do? Communicate Report incidents Open and honest culture Contribute to risk assessments and audit Put safety top of your priorities – ‘ do no harm Ask for help Don’t take short cuts Legible writing

Priorities Strategy Implementation / Development Maternity Strategy for Northern Ireland Midwifery 2020 Perinatal Collaberative- Normalising Birth Maternity Hand Held Record Regional Learning Letters

Role of SAI Group Monitoring Assurance Trends Follow Up Learning

Myths The perfection myth – if we all try hard enough we will not make any mistakes The punishment myth – of we punish people when they make mistakes they will make fewer.

The reality We all make errors, no matter how much training and experience we process, or how motivated we are to do right.

To cover up is unforgivable To fail to learn is inexcusable The Message To err is human To cover up is unforgivable To fail to learn is inexcusable While the evidence ogf the link between nurse staffing and patient safety is clear – Why hasn't nursing been given a higher priority on a national safety agendas. Much of the attention has been on preventing errors but less on the latent conditions that increase the risk of errors – The evidenc is there – Safe nurse staff – is sfae pateint care There is evidence that if you address the latent causes then you will have a greater impact on safety and at a greater speed.

Ensure that the urgent doesn’t crowd out the important ALWAYS Ensure that the urgent doesn’t crowd out the important