Patient Safety in Maternity Care: Towards Better Outcomes
thesis
posted on 2017-04-04, 00:17 authored by Suzanne Sinni“A healthy start to
life” is a health research priority of the National Health and Medical Research
Council (NHMRC). Such a start to life is, in no small way, dependant upon both
a healthy pregnant woman and high quality care during her pregnancy, labour and
postpartum. In Australia, 99 of every 100 babies are born in hospital. While
their mothers may receive care during their pregnancy in an array of settings,
acute public health services are the major provider of care.
When Monash Health (formerly Southern Health), Victoria’s largest provider of maternity care, opened a new maternity service, encompassing outpatient antenatal, inpatient intrapartum and immediate postpartum, and domiciliary postpartum pregnancy care, in a new green-field site hospital a formal evaluation of the service was planned to provide both detailed information about the quality of the new service and insights into opportunities for care enhancement at its other two existing sites. The work detailed in this thesis is the result of that evaluation and of a broader view at the provision of safe maternity care. The underlying premise of the evaluation was that the highest priority for the service was safety. As such, I endeavoured to measure the safety of the service. The approach that I took to measure safety was influenced by the international momentum to improve patient safety and by the growing and increasingly informed debate about how to measure patient safety. The resultant mixed methods approach is intended to provide rich and detailed data about the pregnancy (antenatal) care provided by the service. Pregnancy care was considered a useful measure of the service on the assumption that quality pregnancy care reduces the risk of unexpected poor outcomes. Whilst an evaluation of intrapartum care, in addition to pregnancy care, would provide a more comprehensive evaluation of the service such an evaluation was beyond the scope of this PhD. At the outset, I had hoped that the data would usefully inform the service about opportunities for future patient safety initiatives in its maternity services and I am pleased to have been told that that has been so. Since I commenced my doctoral research Victorian public maternity services have been rocked by findings of a review of Djerriwarrh Health Service’s maternity service. While the detailed findings of that review have not been made public the summary findings echoed the need for all services to have a mature and embedded culture of safety. In that regard, I hope that my findings may also offer useful insights to others responsible for maternity services more broadly.
The research reported in the thesis is divided into quantitative and qualitative components. The quantitative research involved the development and validation of an audit tool (Chapter Three) that was then applied to measure actual health care delivery against those standards (Chapter Four) as recorded in the health records of women attending the new maternity service for their pregnancy care. At the research site, episodes of care were documented in hard copy and retained in a health record. A copy of the health record is scanned and stored electronically. While this facilitated access to records the inherent challenges of legibility and missing information in an unregulated hardcopy medical records system remained. In addition, the complex reporting required of clinicians likely confounded data completion and veracity as clinicians, at least apparently, struggled to ensure completion of duplicate information on various unconnected platforms. Of course, this observation in itself was inherent in an overall assessment of safety and I refer to the matter in the relevant Discussion in Chapter Four, providing recommendations for future service design and development. Despite these challenges, my review of pregnancy care, measured against a pre-defined template of standards of care, suggested that there was a
high level of compliance with organisational expectations reflective of a high quality service (Chapter Four).
Current concepts of patient safety internationally also influenced my use of qualitative research. Hospitals in the United State of America (USA) regularly conduct surveys of hospital staff as a component of assessing the hospital’s culture of patient safety. This survey was used to develop prompt questions for interviews with staff involved with maternity care at the research site about their perceptions of the safety and quality of the service in which they work. The semi-structured interviews yielded qualitative data for thematic analysis, described in Chapter Five, and indicated that staff perceived their service to be safe and of high quality. Nonetheless, staff, regardless of discipline or seniority referred to numerous systems at various organizational levels to optimise patient safety. Staff emphasised the influence of relationships and the importance of respect on team performance. These and other service improvement opportunities identified by the mixed method approach that I used are explored in depth across Chapters Four, Five, and Six.
The results reported herein reassure that the service is safe, with lower error rates than those reported in the literature for acute medical and surgical settings. However, the usefulness of such comparisons is debatable, prompting the need for ongoing research measuring patient safety, particularly in pregnancy care. The qualitative results detailed in Chapter Five reaffirm the high standards of care, arguably attributable to the high levels of trust and mutual respect among senior staff.
When Monash Health (formerly Southern Health), Victoria’s largest provider of maternity care, opened a new maternity service, encompassing outpatient antenatal, inpatient intrapartum and immediate postpartum, and domiciliary postpartum pregnancy care, in a new green-field site hospital a formal evaluation of the service was planned to provide both detailed information about the quality of the new service and insights into opportunities for care enhancement at its other two existing sites. The work detailed in this thesis is the result of that evaluation and of a broader view at the provision of safe maternity care. The underlying premise of the evaluation was that the highest priority for the service was safety. As such, I endeavoured to measure the safety of the service. The approach that I took to measure safety was influenced by the international momentum to improve patient safety and by the growing and increasingly informed debate about how to measure patient safety. The resultant mixed methods approach is intended to provide rich and detailed data about the pregnancy (antenatal) care provided by the service. Pregnancy care was considered a useful measure of the service on the assumption that quality pregnancy care reduces the risk of unexpected poor outcomes. Whilst an evaluation of intrapartum care, in addition to pregnancy care, would provide a more comprehensive evaluation of the service such an evaluation was beyond the scope of this PhD. At the outset, I had hoped that the data would usefully inform the service about opportunities for future patient safety initiatives in its maternity services and I am pleased to have been told that that has been so. Since I commenced my doctoral research Victorian public maternity services have been rocked by findings of a review of Djerriwarrh Health Service’s maternity service. While the detailed findings of that review have not been made public the summary findings echoed the need for all services to have a mature and embedded culture of safety. In that regard, I hope that my findings may also offer useful insights to others responsible for maternity services more broadly.
The research reported in the thesis is divided into quantitative and qualitative components. The quantitative research involved the development and validation of an audit tool (Chapter Three) that was then applied to measure actual health care delivery against those standards (Chapter Four) as recorded in the health records of women attending the new maternity service for their pregnancy care. At the research site, episodes of care were documented in hard copy and retained in a health record. A copy of the health record is scanned and stored electronically. While this facilitated access to records the inherent challenges of legibility and missing information in an unregulated hardcopy medical records system remained. In addition, the complex reporting required of clinicians likely confounded data completion and veracity as clinicians, at least apparently, struggled to ensure completion of duplicate information on various unconnected platforms. Of course, this observation in itself was inherent in an overall assessment of safety and I refer to the matter in the relevant Discussion in Chapter Four, providing recommendations for future service design and development. Despite these challenges, my review of pregnancy care, measured against a pre-defined template of standards of care, suggested that there was a
high level of compliance with organisational expectations reflective of a high quality service (Chapter Four).
Current concepts of patient safety internationally also influenced my use of qualitative research. Hospitals in the United State of America (USA) regularly conduct surveys of hospital staff as a component of assessing the hospital’s culture of patient safety. This survey was used to develop prompt questions for interviews with staff involved with maternity care at the research site about their perceptions of the safety and quality of the service in which they work. The semi-structured interviews yielded qualitative data for thematic analysis, described in Chapter Five, and indicated that staff perceived their service to be safe and of high quality. Nonetheless, staff, regardless of discipline or seniority referred to numerous systems at various organizational levels to optimise patient safety. Staff emphasised the influence of relationships and the importance of respect on team performance. These and other service improvement opportunities identified by the mixed method approach that I used are explored in depth across Chapters Four, Five, and Six.
The results reported herein reassure that the service is safe, with lower error rates than those reported in the literature for acute medical and surgical settings. However, the usefulness of such comparisons is debatable, prompting the need for ongoing research measuring patient safety, particularly in pregnancy care. The qualitative results detailed in Chapter Five reaffirm the high standards of care, arguably attributable to the high levels of trust and mutual respect among senior staff.
