Maternity Services Annual Report 2013

Transcription

TAIRAWHITI DISTRICT HEALTH
MATERNITY ANNUAL REPORT
1 July 2012 to 30 June 2013
Private Bag 7001, Gisborne 4040,
421 Ormond Rd, Gisborne 4010
NEW ZEALAND
Tairawhiti DHB are proud to be part of the Midland Region
Contents
Acknowledgements ..................................................................................................... 3
Message from the Maternity Clinical Leader(s) ......................................................... 4
Purpose of this report .................................................................................................... 4
Message from the Chair, Midland Maternity Action Group ..................................... 5
Our Vision....................................................................................................................... 6
Background................................................................................................................... 7
Maternity Outcomes .................................................................................................... 8
SECTION ONE: AIMS / OBJECTIVES OF THE TAIRAWHITI MATERNITY SERVICE AND MQSP ...........8
SECTION TWO: DATA ANALYSIS .......................................................................................................... 13
SECTION THREE: MQSP GOVERNANCE AND OPERATIONS............................................................ 20
SECTION FOUR: QUALITY IMPROVEMENT .......................................................................................... 24
SECTION FIVE: MQSP STRATEGIC PLAN DELIVERABLES ................................................................... 34
Appendices................................................................................................................. 44
Appendix 1
Midland Regional Services Plan – Maternity Work Programme 2012/2013
(including detail on regional progress as at June 2013) ............................................................... 44
Appendix 2
Terms of Reference – MQSF ...................................................................................... 56
Appendix 3
Maternal Mental Health Referral Flowchart .......................................................... 62
Appendix 4
Audit Schedule for Maternity Services 2013........................................................... 63
Page | 2
TDH Maternity Annual Report - FINAL
Acknowledgements
The following people are acknowledged for their contribution to this report:
 Tiziana Manea – Maternity Quality and Safety Programme Project Coordinator
 Lou Clearwater – TDH Maternity Quality and Safety Forum Consumer Representative
 Nicki Dever – Clinical Care Manager of Women Child & Youth Clinical Care Group
 Diane Van de Mark – Head of Department Womens Health/O& G
 Elizabeth Baxter – Acting Clinical Midwife Manager/Midwifery Educator and Quality
Coordinator
 Judi Murphy – Smoking Cessation, BFHI, Breastfeeding, Safe Sleep Project Coordinator
 Mary-Clare Reilly – Clinical Midwife Manager
 Kay Symes – Violence Intervention Programme Coordinator
 Amy Wray - Lactation Consultant Services
 Maternity Quality and Safety Governance Group members (including LMC representation)
Message from the Maternity Consumer Representative and Clinical Leaders
Kia Ora,
WOW! We are well on our way to providing our mums, whanau and health professionals with the
best maternity service for the Tairawhiti district.
There has been a lot of work done to put TDH's Maternity Quality and Safety Strategic plan into
action, with positive transformations, use of new tools and better communication, all making
amazing improvement in our services.
Even though there is still a lot of work to be done to reach all the goals, we are extremely lucky to
have the amazing people we have working hard to achieve these goals and I would like to personally
thank and thank on behalf of our mums, present and future, and their whanau the great team for
their hard work and dedication to this project
Thank you all.
Arohanui,
Lou Clearwater
TDH Consumer Representative
Page | 3
Message from the Maternity Clinical Leader(s)
According to the well-known quotation, “it takes a village to raise a child”
In the same vein, it takes a community of committed people to care for a pregnant woman.
The many individuals whose efforts are represented in this report have made a measurable
difference to the quality and safety of maternity care in Tairawhiti, creating a network of support for
our mothers and babies.
“Together we are making a difference”.
We continue to strive for improvement, more cohesive teamwork and communication.
We have worked towards better integration of PMMRC recommendations and will continue this
work in the next year to ensure we provide a quality, safe service for women and together continue
to learn and respond.
Diane Van de Mark
Head of Department
Women’s Health
Nicki Dever
Clinical Care Manager
Women, Child & Youth
Purpose of this report
This Annual Report covers the implementation and outcomes of Tairawhiti’s Maternity Quality &
Safety Programme in 2012/2013, as required under section 2.2c of the Maternity Quality & Safety
Programme Crown Funding Agreement (CFA) Variation (Schedule B42):
This Annual Report:
 demonstrates Tairawhiti’s delivery of the expected outputs as set out in Section 2 of the
Maternity Quality and Safety Programme CFA Variation
 outlines progress towards Tairawhiti’s MQSP Strategic Plan deliverables in 2012/13
 describes Tairawhiti’s planning undertaken, or intended to be undertaken, to improve the
quality and safety of its maternity services in 2013/14.
Page | 4
Message from the Chair, Midland Maternity Action Group
The Midland Maternity Action Group was established in 2011, the group includes stakeholders from
across the five Midland DHBs. The current membership is:
 BOP DHB: Marg Norris (Midwifery Leader), Bill McCauley (O&G HOD), Sachit Gagneja
(MQ&SP)
 Lakes DHB: Dale Oliff (COO), Simon Ewen (O&G HOD), Sue Finch (Clinical Midwife Manager/
MQ&SP)
 Waikato DHB: Ruth Galvin (Planner / MQ&SP), Sue Hayward (DON&M), Corli Roodt (Clinical
Midwife Director / MMAG Chair), Pip Wright (Midwife Educator), Clare Hutchinson (
Hamilton LMC, River Ridge East Birth Centre)
 Taranaki DHB: Belinda Chapman (Assoc. Director of Midwifery/ MQ&SP)
 Tairawhiti DHB: Nicki Dever (Clinical Care Manager, Women Child & Youth Clinical Care
Group), Mary-Clare Reilly (Clinical Midwife Manager)
 GMs Maori Health: Jade Chase (Waikato DHB)
 Communications: Mary Anne Gill (Waikato DHB)
 HealthShare: Suzanne Andrew (Project Manager), Philippa Edwards (Data Analyst)
The primary purpose of the group is to lead regional activity, including implementation of maternity
actions on behalf of the Midland DHBs, and to provide expert technical advice to the DHB CEOs with
a focus on sustainable service delivery through quality improvement and workforce development
activities.
The outcome of this regional approach is to facilitate improved coordination and responsiveness of
services across the Midland region provided to those women and their families requiring maternity
services.
The group to date have focused on educational and quality activities focused on improving access to
education to the region’s maternity workforce, and supporting a standardised approach to delivery
of maternity services through improved communication, sharing of resources, reducing duplication
and the development of initiatives, that when done collaboratively, will improve efficiency and
effectiveness across the five DHBs.
The group looks forward to continuing its work and collectively facing the challenges associated with
identifying opportunities to continue to provide sustainable quality maternity services to the
communities across the Midland Region.
Corli Roodt, Clinical Midwife Director, Waikato DHB
Chair, Midland Maternity Action Group
Page | 5
Our Vision
The Tairawhiti District Health (TDH) mission is;
“Mahia nga mahi i roto i te kotahitanga kia piki ake to oranga o te Tairawhiti” “Working together
to elevate the wellbeing of Tairawhiti”
The vision for the TDH maternity services is;
“To provide evidence informed/based maternity services which are seamless, culturally
appropriate, woman-centred, and integrated within the Tairawhiti community”.
Since the introduction of the Maternity Quality and Safety Programme (MQSP) we have been
building on the existing structures of the maternity services in Tairawhiti and have the vision of;
“Clinical Leadership and Partnership in Action - Keeping the woman at the centre of care in TDH’s
Maternity Services”
This is illustrated in the following image:
Page | 6
Background
Alignment with New Zealand Maternity Standards
This Annual Report has been developed to meet the expectations of the New Zealand Maternity
Standards (as set out below).
Expectations of the New Zealand Maternity Standards:
Standard One:
Maternity services provide safe, high-quality services that are nationally consistent and
achieve optimal health outcomes for mothers and babies
8.2
Report on implementation of findings and recommendations from multidisciplinary
meetings
8.4
Produce an annual maternity report
8.5
Demonstrate that consumer representatives are involved in the audit of maternity services
at Tairawhiti
9.1
Plan, provide and report on appropriate and accessible maternity services to meet the
needs of Tairawhiti
9.2
Identify and report on the groups of women within their population who are accessing
maternity services, and whether they have additional health and social needs
Standard Two:
Maternity services ensure a women-centred approach that acknowledges pregnancy and
childbirth as a normal life stage.
17.2
Demonstrate in the annual maternity report how Tairawhiti have responded to consumer
feedback on whether services are culturally safe and appropriate
19.2
Report on the proportion of women accessing continuity of care from a Lead Maternity
Carer for primary maternity care
Standard Three:
All women have access to a nationally consistent, comprehensive range of maternity
services that are funded and provided appropriately to ensure there are no financial
barriers to access for eligible women.
24.1
Report on implementation of the Maternity Referral Guidelines processes for transfer of
clinical responsibility
Page | 7
Maternity Outcomes
SECTION ONE: AIMS / OBJECTIVES OF THE TAIRAWHITI MATERNITY SERVICE AND
MQSP
Summary of aims/objectives of Tairawhiti’s MQSP for first year:
The Tairawhiti maternity services and MQSP aims to provide, monitor and action improvements in
services to optimise safety for women, babies, families/whanau, service users and service providers
of Tairawhiti.
Tairawhiti DHB also participates and collaborates with the 4 other Midland regional DHB’s through
the Midland Maternity Action Group (MMAG), Midland Midwifery Leaders group (MML) and the
Midland Regional Educators sub-group and are working towards sharing education sessions and
templates, protocols and other strategies to reduce duplication, workloads and increase efficiency
and networking.
As a relatively small District Health Board, our maternity service providers have the advantage of
collaborative, collegial working relationships and strong clinical leadership.
As stated in the TDH Maternity Strategic Plan 2012/13 we set out to develop, improve and sustain
the following areas during the first Year of the MQSP:
1. Comprehensive program for quality improvements in Maternity
2. Strategic approach to collection, reporting and analysis of maternity data
3. Overarching multidisciplinary governance group
4. Increase linkage between primary and secondary maternity sectors
5. Defined process for consumer engagement
6. Appropriate resources and infrastructure to implement and maintain the programme
Please refer to the Work Programme review below 2012-2013 to demonstrate this:
Please also refer to specific information throughout the report as evidence
Alignment of aims/objectives (above) with national priority and recommendations:
Priority:
GOVERNANCE:
a. The membership mix of the maternity services committee (now MSQF)
will align with the national requirement for a local multidisciplinary
quality group, increasing consumer, GP, core midwives, and lactation
service involvement
b. Complete an annual maternity services strategic plan
c. As per the updated ‘Referral Guidelines’ and ‘Secondary Care
Specifications’, we will ensure that local processes are in place, clear to
everyone, and communicated, so that women know who is responsible
for their care at all times
d. Induction of labour (IOL) care plan in place
INFORMATION AND COMMUNICATION SYSTEMS:
a. Improve our information and communication networks within the
Tairawhiti community. Ensure all providers are ‘connected’ in delivering
woman-centred services by establishing, and advertising widely,
consumer and community stakeholders forum/workshops
Status:
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
PARTIALLY
Workshops moved to
2013/14 to present
annual report
Page | 8
b.
Confirm the key stakeholders in Tairawhiti, including iwi providers, and
identify GPs who want to be a part of MSQF and other activities Identify
and meet with all agencies that deliver services for pregnant women
and young babies, to look at gaps and identify needs.
Feedback to MSQF to plan better linkages, improve communication
processes and develop action plan
c. Monthly ‘Maternity Matters’ newsletter to all key stakeholders to align
with MSQF updates
d. Develop framework for logistical support and/or financial compensation
for LMCs and consumers to participate and take forward quality
improvement activities
DATA MONITORING:
a. Consider areas for improvement from the NZ Clinical Indicators and
Health Round Table (HRT) data for our region to inform our Strategic
Plan and annual plan
b. Work on strategies to reduce the incidence of 3rd and 4th degree tears 6 month rate July to December 2011 2.5% - reduce by at least 0.5% July
to December 2012
c. Work on becoming an early implementer for the National Maternity
Database
d.
Follow the PMMRC 2012 recommendation to reduce the incidence of
maternal suicide (most frequent cause of death 2006-2010) by
developing a comprehensive perinatal and infant mental health service
to include screening and assessment, timely intervention, specialist
inpatient care for mothers and babies, consultation and liaison services.
COORDINATION AND ADMINISTRATION:
a. Align our monthly Maternity Services Committee (MSQF) meetings with
national requirements for the Maternity Quality and Safety Programme
b. Increase the membership of the MSQF to enhance integration and
participation
SECTOR ENGAGEMENT:
a. Work towards achieving the local goals of the National Maternity
Quality and Safety Programme targets, as set out in the 2012/2013
Work Programme Midland Maternity Action Group Midland Regional
Service Plan, whilst meaningfully involving all key stakeholders e.g. Iwi
providers, well child providers, GP’s.
b. Project Co-ordinator in place from 05/2012 – work on MMAG plan when
all other leads are in place
c. Develop strong relationships with local Iwi providers
d. Draft a communications ‘tree’ representing a cascading information
framework, aiming to include all key stakeholders, and send this out for
consultation
e.
Collate information on all key stakeholders and obtain contact details
CONSUMER ENGAGEMENT:
a. Utilise existing national and regional feedback systems and act on
ACHIEVED
ACHIEVED through
other publications
Waiting for Regional
signoff of framework
ACHIEVED
ACHIEVED
Further work 2013/14
ACHIEVED
implementation in
progress
ACHIEVED further work
2013/14
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
NOT ACHIEVED but
replaced with link to
Mama & Pepi action
group
Work in progress across
sector
ACHIEVED
Page | 9
b.
c.
d.
recommendations for consumers who are, or have recently engaged, in
the maternity services. Providers to share outcomes and improvements
collectively
Develop culturally appropriate and culturally led methodology of
consumer feedback e.g. surveys and focus groups
Survey local consumers with appropriate cultural guidance and support
(see Appendix 5)
Prioritise increasing consumer (ensuring Maori consumers) involvement
and communication processes
2013/14
2013/14
ACHIEVED in
partnership with Iwi
providers. Further work
2013/14
QUALITY IMPROVEMENT:
ACHIEVED by 100%
1. Investigate proactive ways of increasing attendance at weekly
multidisciplinary quality meetings by 10%
2. Produce a documented process of effective communication
flow/linkages, from quality improvement activities such as the weekly
multidisciplinary quality meetings, incident reporting, monthly perinatal
mortality and morbidity meetings, case reviews, sentinel events, debriefing, etc., to ensure recommendations are actioned by all key
personnel and integrated into daily practice
3. Publish a Maternity Annual Report each year from June 2013,
summarising the key achievements and outcomes in relation to the
National Maternity Quality and Safety Programme. It will include local
and regional information relating to the New Zealand Maternity Clinical
Indicators
ACHIEVED but ongoing tabled in MQSF –
objective 2013/14
ACHIEVED 2013 but
ongoing
ACHIEVED
4. Achieve BFHI reaccreditation and develop an annual plan for
breastfeeding. Best practice related education for all staff and LMCs and
key stakeholders in the community
5. Reduce the rate of smoking pregnant women. Increase knowledge of
smokefree messages and education to women. Increase referral rate to
community cessation providers to 90%
6. Liaise with smoking cessation providers and link with healthcare
IN PROGRESS
Objective for 2013/14
ACHIEVED
professionals
7. Increase health professional’s awareness and knowledge of safe sleep
messages. Safe sleep policy in maternity unit. Plan a coordinated
approach to safe sleep in the community
8. Ensure 100% referral to Well Child Provider and early enrolment with
GP
ACHIEVED Objective for
2013/14
IN PROGRESS
Objective for 2013/14
Page | 10
Identified maternity services challenges for TDH
1. Improving the environment of care
2. Training and education
3. Specialist care
4. Workforce
5. Staff appraisals
6. Information technology
7. Patient transfer
Steps taken or planned to address issues
1. Improving the environment of care
This initiative has been a work in progress in the delivery unit and antenatal/postnatal ward:
Elizabeth Baxter- Acting Clinical Midwife Manager/Midwife Educator and Quality Coordinator pictured in a newly decorated birthing room.
Gisborne Maternity Unit - Puawai Aroha (literal meaning ‘The Blossoming of Love’)
 Reinforced maori name of unit so everyone is now aware of meaning
 All delivery rooms painted
 Antenatal/Postnatal rooms currently being painted
 New curtains and matching bedspreads in every delivery room
 New delivery beds (all personnel have been trained to use it efficiently)
 Equipment purchased: blanket warmer; new caesarean section cot; obstetric emergency
trolley; new epidural trolley; new ultrasound machine; opthalmoscope
 Artwork yet to be purchased (Maori midwife representative currently liaising with local
artists)
 Official opening ceremony planned once artwork is purchased
2. Training and Education
 RANZCOG training for all staff including O&Gs (planned every two years was completed in
June 2012).
 Practical Obstetric Multi Professional Training (PROMPT) course (to enhance team work) was
reintroduced locally commencing 26/6/2013 aiming at having 2 sessions yearly. Purchasing
of Sophie doll as a training tool.
 All O&Gs and midwives are orientated into the K2 and Section 88 Maternity Standards
within the first week of their employment.
Page | 11







All staff including Neonatal attend the Tikanga Best Practice and Te Kete Kawarau cultural
training.
All O&Gs, maternity and neonatal staff attend the open disclosure; BHFI; online smoking
cessation and baby essentials; epidural ; breastfeeding ; mental health pathway;
documentation workshops.
The Maternity and the Neonatal Unit have increased collaboration in skills and team
building. All midwives have received orientation in the operating theatres and proper use of
equipment. Neonatal unit staff will receive the same orientation to assist in multiple births
and neonatal resuscitation. This initiative is to assist the maternity services during the
shortage of midwives with the objective of better collaboration, team building, skill mix and
provision of care.
Antenatal clinic midwife has completed training to immunise expectant mothers against
whooping cough and influenza whilst visiting the clinic (immunisation program commenced
in May), evaluation of this initiative will be included in the 2013-2014 plan).
Newborn screening and universal HIV screening update by the MoH was offered to all staff,
LMC, GP and practice nurses in TDH on 12/13 April 2013.
Quality leadership programme has been introduced.
Documentation workshops completed.
3. Specialist Care
 Diabetic clinic has been operating weekly since January 2013.
 Local diabetes guideline updated as an interim until national guideline approved and
implemented.
 O&G clinic offered monthly in remote rural primary birth location (Te Puia Springs).
4. Workforce
Recruitment and retention is still a high priority for the maternity services, we have:
 A full complement of O&Gs within the service
 A replacement Clinical Midwife Manager has been appointed; she has commenced her role
in May 2013. An interim Clinical Midwife Manager was appointed in February 2013. Will
have close links with DON/Midwifery
 An initial Maternity Quality and Safety Project Coordinator was appointed in March 2012.
 A new Maternity Quality and Safety Project Coordinator was appointed in October 2012.
Transition to ‘business as usual’ from August 2013
 Two midwives on the First Year of Practice program (locally trained) which is important for
our unique community
 We have expanded the recruitment drive into international forums to attract core midwives
 Recruitment is ongoing and continues to be a challenge. Close links with region when
recruiting (e.g. passport through MMAG).
 Our obstetric workforce has been well staffed for the past two years with longer term
locums, as well as the stability of our HoD Obstetrics and Gynaecology and Clinical Director
Women, Child & Youth
5. Staff appraisals
 are not being completed as timely as TDH would like
 new clinical midwife manager will schedule as a priority
6. Information Technology
 TDH currently operates the “Galen InteHealth Perinatal” maternity information system, for
which the vendor “iSOFT” (now CSC) issued an “end of life” notice.
Page | 12



The MoH in conjunction with the NHIT Board have entered into a contractual agreement
with “CleverMed”, a UK based company, to deploy their “BadgerNet” maternity information
system as a single national system for use by all NZ DHBs.
In preparation for the introduction of BadgerNet (Maternity Information System) there has
been an in-depth review of current business and clinical processes. TDH is the first early
adopter in New Zealand.
Areas for improvement in the future will be the timeliness of discharge summaries being
sent to GPs – which is being addressed.
7. Patient Transfer
 Robust Patient Transfer plan has been designed at Regional level. Feedback is being sought
from each DHB involved which will be followed by the implementation phase.
SECTION TWO: DATA ANALYSIS
Summary of maternity services provided in Tairawhiti
Due to unavailability of maternity data 2012 at this stage, the data used for this report is for year
2011 provided by MoH
1. Maternity Facilities
The TDH Maternity Unit, has 13 beds, and is staffed with registered midwives, registered general and
obstetric nurses, and support staff. Although we have been fully staffed at times in the past twelve
months, recruitment and retention of core midwives is an ongoing challenge in order to fulfil the
secondary care service specifications and safe staffing levels. Owing to a current shortage of core
midwives, we frequently have only one core midwife on each shift (the recommended staffing level
is two per shift) and two registered (or obstetric) nurses, but with a midwife on call for emergency
Caesarean sections. Recruiting more midwives is a priority.
We currently have 10 LMCs in Gisborne, with another two LMCs with access agreements caring for
women in remote rural areas and Te Puia Springs (Ngati Porou Hauora Charitable Trust), our Primary
Birthing Unit.
2. Maternal Demographics
In 2011, over 60% of our birthing population identified themselves as ‘Maori’, and 53% of these
women were smokers. According to data from the PMMRC (2012), Tairawhiti has the highest
percentage Maori population in New Zealand (approximately 63%, compared to the next highest of
around 52% in Northland DHB and 48% in Lakes DHB). It is known that Maori and Pacific Island
ethnicities are associated with an increased risk of stillbirth and neonatal death compared with NZ
European (PMMRC 2012).
In the Perinatal and Maternal Mortality Review Committee (PMMRC) Sixth Annual report (2012 - for
2010 births), Tairawhiti had the greatest number of births in the country to homes in the highest
deprivation quintile (5). From this report (2007 - 2010 data), our Perinatal Related Death Rate
(including termination of pregnancy, stillbirths and neonatal deaths) was 9.79/1,000 (national rate
10.1/1,000).
We belong to the Health Round Table (HRT) which collects clinical coding data on all births in the
DHB and primary birthing unit, and from July to December 2011 our Caesarean section rate was
18.3%, the second lowest for secondary or tertiary units in New Zealand (range from 15.5% to
33.5%). In 2009 our Caesarean section rate was around 25% (from TDH Maternity Unit statistics), so
Page | 13
this is a significant decrease in interventions and one that had been identified as a priority to work
on reducing as a team. We continually review our operative birth rate to minimise unnecessary
medical interventions, through weekly multidisciplinary quality case review meetings.
In 2011 our home birth rate (Statistics New Zealand) was 8.26%. Nationally it is challenging to
collect accurate data on home births, though the New Zealand College of Midwives indicate that
home births are on the increase with the national rate recently rising to approximately 7%. We will
improve our data collection with a local process.
% Single Still Births over 2009-10-11, Source:MOH Mothers Data
1.20%
2009 Bay of Plenty
2010 Bay of Plenty
2011 Bay of Plenty
2009 Lakes
2010 Lakes
2011 Lakes
2009 Tairawhiti
2010 Tairawhiti
2011 Tairawhiti
2009 Taranaki
2010 Taranaki
2011 Taranaki
2009 Waikato
2010 Waikato
2011 Waikato
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
Page | 14
Summary of uptake of maternity services and associated data
1. Early registration with an LMC
2. Smoking Cessation
3. Sudden Unexpected Death in Infancy (SUDI) Prevention
4. Maternal Mental Health referral pathway
5. Vulnerable Pregnant Women
Early Registration with LMC
TDH acknowledges LMC registration timing as one of the priority work stream for MQSP in
compliance with NMMG priorities. Analysis of the data provided by the Ministry of Health and the
National Maternity Monitoring Group has the following key points:
 As per the data provided by Ministry of Health for the year 2011, 41.82% of all women were
registered with within the first trimester of pregnancy against the national average of 54%
 By the second Trimester, approximately 50.67% of women were registered with LMC against
the national average of 82.10 %
 With these achievements and identified gaps, we understand that there are still some
opportunities of improvement which will strengthen the pathway from primary care to
maternity services. For this purpose, we have established strong working relationship with
community providers of maternity services through MQSP Governance Group to enable
integration of services to support this priority.
 Also it was necessary to better understand the needs/challenges of the district population
which was achieved by bringing additional appropriate people on board for the governance
group (e.g. GP Liaison, Iwi Providers).
LMC Registration by Age:
Tairawhiti LMC Registration in the First Trimerster, by age group
100
80
60
40
20
0
16-19years
20-24years
25-29years
Number of Registrations
Rates of Registration with LMC increases with the increasing age group where Teenage group (16-19
years) are least likely to register with LMC within first trimester
Page | 15
LMC Registration By Ethnicity:
Tairawhiti LMC Registration in the First Trimerster, by ethnicity
60.00%
40.00%
20.00%
0.00%
Maori
Pacific
Other
% of registrations
Maori and Pacific Women are less likely to get registered with LMCs within first trimester of
Pregnancy (36.61% and 29.41% respectively)
Actions to improve:
 The booking gestation has been integrated in the 30-36+6 premature births audit (presented
at the end of January 2013 at the perinatal meeting)
 As part of the communication plan to reach consumer and stakeholders early booking is to
be incorporated and highlighted as a priority.
As part of the initiative we will:
 Further clarity with MoH for recommended gestation for registration (PMMRC 10weeksNMMG 14 weeks- Child & Youth Health Compass 12 weeks) to ensure consistent message
to consumers
 Dissemination of above messages to LMCs
 Involvement of GP liaison to disseminate PMMRC/National Maternity Mortality Group
(NMMG) recommendation for early registration (alignment of service provision for first
trimester care)
 Advertising through local paper provision of free pregnancy testing in midwives clinic with
the intent to provide LMC contact and promote early booking (e.g. The Eastland trader)
Following the National Maternity Monitoring Group request for information on initiatives to
encourage early booking, the Maternity Quality and Safety Programme Coordinator consulted with
representatives from the two midwifery practices in Gisborne and the following existing factors were
identified:
 Location; Practice A. is centrally located, sharing the building with a newly established GP
practice. Practice B. is located in a predominantly Maori populated area of Gisborne in a local iwi
owned building (Ngati Porou Hauora)
 Strategies; Practice A. is in the process of developing a direct link with the practice GPS. Practice
B. offers a 0800 telephone number; it also shares the building with the Mama and Pepi service;
smoking cessation provider, antenatal classes’ provider, Safe Sleep Education ProviderWahakura Weaving Group and a lactation consultancy service. Practice B. is also is in the process
of approaching three different GP practices to create a direct link. There is a strong whanau
oriented link for midwives that have been practicing in the area for a number of years. Some
LMC offer antenatal home visits for some clients
 Practice nurse/midwife; it was highlighted by both practices that the most efficient/seamless
referral pathway was through a GP practice whose practice nurse had a midwifery qualification
 Rural midwifery service; services offered by the rural midwives are based on antenatal home
visits, birth services are offered in the primary rural unit
Page | 16
Smoking Cessation Programme in TDH
Documentation data of the provision of smoking cessation education for every maternity admission
is shown in the following graph:
Maternity Support to Quit (Hospital Only)
100
80
60
40
Jun-…
Apr-…
May…
Mar…
Feb-…
Jan-…
Dec-…
Nov…
Oct-…
Sep-…
Aug…
Jul-12
Jun-…
Apr-…
May…
Mar…
0
Feb-…
20
Jan-…
% offered support to quit
120
Smoking cessation education has been completed by all staff in TDH (ongoing).
Non achievement of the 95% target at times has been overcome by the introduction of the new
postnatal care plans which prompt discussion and enable documentation to be completed clearly.
Also included in the updated care plans is a focus on safe sleep and breastfeeding information given
to women.
An initiative from the BFHI/smoking cessation/safe sleep/breastfeeding project coordinator was to
extend smoking cessation intervention education to sonographers with the aim to reduce smoking in
pregnancy prior to 15 weeks gestation and early referral to cessation provider for ongoing support.
The ultrasound department have completed the ABC information and education online for women.
Sudden Unexpected Death in Infancy (SUDI) Prevention
Rate per 100,000 SUDI Infant Deaths by DHB of Domicile, 2006-2010
2.0
Waikato
1.5
Lakes
1.0
Bay of Plenty
Taranaki
0.5
Tairawhiti
0.0
SUDI infant death rate (per 100,000 population)
A safe sleep policy has been in place since 2013. Regional policy is being processed.
A Pepi pod program was launched in April 2013. Funding from the Gisborne Hospital Trust was
granted for the purchase of an initial 30 pepi pods. Alternative funding was sourced from Planning
and Funding.
Distribution of these pods is included in the Mama and Pepi contracts held by the two local iwi
providers, Ngati Porou Hauora and Turanga Health. A MoU is in place with Change for our Children
Ltd who has provided training for the distributors and are the source of the Pepi Pods. Referral for a
Wahakura or Pepi Pod can come from the maternity or neonatal unit at the time of birth or
antenatally from the LMC. It is acknowledged that the Wahakura is the most appropriate option if
the whanau are willing or able to be part of the weaving program but the Pepi Pod provides a readily
available safe sleep option. An integral part of both programs is for mother and whanau to receive,
Page | 17
detailed advice around safe and smoking cessation and to pass the safe sleep message on to their
friends and family.
The programs are targeted to reach Maori women and their whanau, women who smoke in
pregnancy, pre term babies or babies who live in a household where there is regular smoking,
alcohol or drug use.
Maternal Mental Health
It has been identified that the GP remains the primary point of referral for women who require
mental health support, presently there is no data available from GPs.
It was recognised, following the submission of the TDH Maternity Strategic Plan in May 2012, the
omission of reference to the 2012 recommendation of the PMMRC. In the November 2012 update of
the document it was added under the following heading:
 Key Priorities:
“Following the PMMRC 2012 recommendation to reduce the incidence of maternal suicide (most
frequent cause of death 2006-2010) by developing a comprehensive perinatal and infant mental
health service to include screening and assessment, timely intervention, specialist inpatient care for
mothers and babies, consultation and liaison services”.
Action taken:
A local referral pathway was developed with input from mental health, addiction services and
maternity services. Pathway has been presented to local MQSF and mental health governance
groups.
Compulsory workshops were held to educate maternal and mental health staff in the importance of
screening, assessment and treatment options in this population group
Topics included:
 Maternity Mental Health risk factors
 Prevention and screening tools/ tools to determine to determine levels of psychological
distress, suicide risk and alcohol and other drug use in women in maternity services.
 Working with people who feel suicidal
It has been recommended by the Clinical Nurse Specialist Mental Health that the tool be used by all
LMCs during antenatal care (around 28 weeks) and postnatally (between weeks 2-3) prior to
discharge. The use of this tool falls in line with the regions primary and secondary mental health
services “stepped care” approach to mental health. This approach delivers and monitors treatments
so that the most effective yet least resource intensive treatment is used stepping up as need be.
Midlands Health Network currently provide Primary Mental Health services to the region - the local
GPs and Primary Mental Health team use the Kessler 10 (K10) as an assessment tool and also as an
outcome measurement. DHB has provided a copy of this tool to all LMCs.
The flowchart provides an action plan following screening for mental health during the woman’s
journey through her pregnancy (see appendix 3).
Maternity Services now have a maternal mental health “Champion” who will be a “go to” person for
advice. The importance of multi-agency collaboration is being reinforced and mental health services
advocate that all clinicians involved feedback to LMC.
Evaluation of the referral pathway will be included in the 2013-2014 plan
Page | 18
Vulnerable Pregnant Women
VPW Referrals for the period July 2012 to June 2013
10
8
6
4
2
0
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Average
Referrals to Vulnerable Pregnant Womens MDT
The Vulnerable Pregnant Women Multi-Disciplinary (MDT) meeting is an initiative driven by the
Violence Intervention Programme (VIP) within Tairawhiti District Health (TDH).
The Violence Intervention Programme is a national programme which is embedded in all twenty
district health boards throughout New Zealand.
Given the prevalence of pregnant women who were identified through the Tairawhiti Abuse
Intervention network case management meeting as well as the number of case consultations
requested by TDH staff to discuss suspected or confirmed partner abuse the need to create an early
intervention MDT was identified.
The Vulnerable Pregnant Women MDT enables appropriate professionals to discuss concerns and
establish a pathway of action. Decisions and/or outcomes therefore are shared thus providing
support to professional practice and early and effective intervention to the unborn child, pregnant
woman and her family / whanau.
A plan to incorporate the vulnerable women group as part of the MQSP and governance group will
be included in the 2013-2014 priorities. The Clinical Midwife Manager works in partnership with the
VIP Coordinator to provide leadership to the group.
Page | 19
SECTION THREE: MQSP GOVERNANCE AND OPERATIONS
Tairawhiti’s MQSP governance structure
Please refer to the Terms of Reference for the Maternity Quality and Safety Forum (see Appendix 2)
Page | 20
Tairawhiti’s MQSP governance accountability within the wider Tairawhiti governance
The MQSF will:
 support the service monitor and manage standards of clinical care to ensure they are of a
high quality, with the TDH clinical board and other multidisciplinary clinical teams
 support and facilitate formal clinical governance and clinical practice improvement
processes in TDH
 monitor and review systems, standards, indicators and outcomes which reflect the quality of
clinical care provided within the service
 monitor and oversee regional and local activities associated with:
o The National Maternity Quality and Safety Programme
o The National Maternity Standards
o Maternity Service Specifications
o Section 88 (Referral Guidelines)
o The Clinical Indicators
o Referral Guidelines
 provide a forum in which decision making and responsibilities for the quality of care are
shared between clinicians and managers
 report these activities to the TDH Clinical Board
 manage the risks of care
New members of the governance structure Maternity Quality and Safety Forum include Iwi
stakeholder Representatives (Mama & Pepi Service) and GP Liaison.
Consumer representation on Tairawhiti’s MQSF
Consumer Representative
A consumer representative participates in the MQSF, NZCOM resolutions committee, collaborates
with the guideline group, assists in disseminating information through publications e.g. (Nerve,
available online through TDH web site).
The consumer has actively collaborated in identifying priorities for the 2013-2014 plan (postnatal
clinic for mothers who need de-brief after a traumatic birth event).
A framework has been developed regionally re a consumer representative role.
Community practitioner representation on Tairawhiti’s MQSF
LMC Representative
The LMC representative participates in the MQSF and feeds back to the LMC group.
A framework has been developed regionally re an LMC representative role.
Perspectives of Maori, Pacific and other groups (as appropriate) represented on Tairawhiti’s MQSF
Maori Midwife Representative
A Maori midwife representative actively participates in the MQSF.
Maori Stakeholder Representative
Iwi Providers (Mama and Pepi services representative) has been integrated as a member of the
MQSF. Mama and Pepi service provide representation in a culturally appropriate context (Mama and
Pepi provide care and support before/during and after pregnancy, antenatal classes, well child
services and referrals to other support agencies to the vulnerable and at risk group mothers in
Tairawhiti)
Page | 21
Mama and Pepi (Outline of Service)
Ngati Porou Hauora and Turanga Health (Iwi providers) have integrated to form the Tairawhiti Mama
& Pepi Service. The Mama & Pepi Service is unique as it provides a holistic approach to education
and care during pregnancy and the postpartum period.
“The vision is to provide our whanau with education and knowledge that will empower and enable
them to make positive changes so they can have a healthy pregnancy and achieve positive and
healthy outcomes”.
The service is based at the heart of midwifery care which enables opportunities to capture our hapu
mothers as they attend their appointments with the midwife during the antenatal period. This
service is designed to meet the needs of the 'at risk' women within Tairawhiti by providing the
following:
 Antenatal classes
 Phone advice
 Kia Mama Breastfeeding Service
 On-site Aukati Kaipaipa smoke
cessation coach
 Postnatal Breastfeeding support
 Media and education resource
development
 Safe sleep education and pepi pod
 Access to free baby clothes
distribution
 Transport to appointments
 Traditional birthing practices-Ipu
whenua workshops
 On-site lactation consultant service
 Other services available through the
service include:
 FREE pregnancy tests-early access to
 Tamariki Ora Well child service
midwifery care
 On-site Wahakura workshops
 Car seat scheme
 One on one antenatal/postnatal
 Tuhono Whanau-Family start
education for vulnerable pregnant
programme
women
 Access to baby clothes
Consumer feedback on Tairawhiti’s MQSP
Consumer feedback is collected and collated from the “compliments and comments” given to every
woman using the maternity services. Complaints/Concerns are responded to in a timely way.
The information is reported to the MQSF monthly, the Multi-Disciplinary Team (MDT) weekly and
the Perinatal meeting quarterly.
Common complaints identified in the last six months were due to lack of thorough cleanliness of the
environment; this was reported to the cleaning supervisor, further training resolved the issues and
this was soon noticed in the subsequent positive feedback.
A post natal care plan has been updated (in relation to trying to improve post natal care and
experiences as noted by MoH national survey results)
Compliments of the care and support received are reported collectively to the midwifery team and
to individual members of staff when named.
A maternity services survey (see Appendix 5) has been developed in consultation and with the
approval of the MQSP governance group. The survey (see Appendix 5) has been distributed
throughout the month of June 2013 (for all women accessing the maternity services, antenatal clinic,
antenatal classes, inpatient labour care, postnatal care, neonatal unit, lactation consultancy services
and the mama and pepi action group). The evaluations of the survey will contribute to the quality
improvement plan for 2013-2014.
Page | 22
Incident Analysis and corrective action
The following outlines the pathway followed for Incident reporting, analysis, corrective action and
monitoring. Please refer to page 32 of annual report which integrates incident reporting with
changes to clinical practice.
Roles established in support of Tairawhiti’s MQSP
 An initial programme coordinator was appointed in March 2012.
 A new programme coordinator was appointed in October 2012.
 The project coordinator has lead actively in:
o Primary and Secondary sector forums
o Weekly multidisciplinary meetings
o Monthly quality meetings (perinatal mortality, guideline)
o Monthly governance meeting (MQSF)
o NNU initiatives
o Audit processes
o Community Hui (quarterly hui run by Mama and Pepi) – includes Iwi Providers, Well
Child Services,
o Immunisation working group
o Early GP enrolment liaison
o First trimester booking with LMC initiatives
 Project Coordinator of smoking cessation, BFHI, Breastfeeding and Safe Sleep is an active
participant in MQSP
 A new Clinical Midwife Manager has been appointed in May 2013. FTE has been increased to
include being a lead coordinator for the local MQSP
 Project Coordinator will transition to Clinical Midwife Manager in August 2013.
Page | 23
SECTION FOUR: QUALITY IMPROVEMENT
Quality improvement actions undertaken in 2012/2013 by Tairawhiti and MQSP, in relation to:
It is noted that the MoH is aware that much of 2012/13 has been focused on setting up the MQS
Programme and that quality improvements will continue to be developed and implemented.
 how the New Zealand Maternity Clinical Indicators, or other data analysis, has been used
to drive quality improvement in Tairawhiti
New Zealand Maternity Clinical Indicators
The Clinical Indicators have highlighted 4 areas for improvement.
 Clinical Indicator 7. Standard primiparae sustaining a 3rd- or 4th-degree perineal tear and no
episiotomy
 Clinical Indicator 9. Women having a general anaesthetic for Caesarean section
 Clinical Indicator 10. Women requiring a blood transfusion with Caesarean section
 Clinical Indicator 12. Premature births (between 32 and 36 weeks gestation)
Trends over the last three years can be identified, a plan of action to drive quality improvement
where indicated is described after each clinical indicator.
Clinical Indicator 1.

Is increasing and remains consistently above national average.

Standard primiparae who have a spontaneous vaginal birth
Standard primiparae who undergo an instrumental vaginal birth
Remains consistently below national average.
Page | 24

Is decreasing and remains consistently below national average.

Standard primiparae who undergo induction of labour
Remains consistently low, below national average.
tear or episiotomy)

Standard primiparae who undergo Caesarean section
Standard primiparae with an intact lower genital tract (no 1st−4th-degree
Remains consistently above national average.
Page | 25
perineal tear

Is decreasing and remains consistently well below national average.
episiotomy

Standard primiparae undergoing episiotomy and no 3rd- or 4th-degree
Standard primiparae sustaining a 3rd- or 4th-degree perineal tear and no
Remains consistently above national average with an increasing trend.
Action taken:
A preliminary audit (not specific to standard primiparae) was done. The audit did not identify
any patterns in a specific practitioner or practice. It did identify inconsistencies in clinical
documentation. Following the preliminary audit two workshops have been organised
(yearly) on the repair of the perineum and clinical documentation which is mandatory for
core staff. A review of the audit to include only standard primiparae was completed in
March 2013 in collaboration with the Obstetric team.
Findings and recommendations for practice changes were presented and discussed at the
Perinatal meeting in April 2013.
In order to address inconsistencies in clinical documentation:
 A proforma was developed to document the correct classification and repair of the
tear which also includes the care pathway
 Follow up for Women to O&G, physiotherapy, referral to ACC entitlement/claim
 The above was developed as a team approach including Physiotherapy
 All of the required documentation is available in a 3rd/4th degree perineal tear
‘bundle’
 Audit and evaluation to be completed in 2013/14.
Page | 26
degree perineal tear

Remains below national average.

Standard primiparae undergoing episiotomy and sustaining a 3rd- or 4th-
Women having a general anaesthetic for Caesarean section
Rate is increasing and is above national average.
Action taken:
An audit was completed in June 2013 in collaboration with the O&Gs and the anaesthetists.
Some factors contributing to the incidence of GA for caesarean sections were identified.
A coding issue was highlighted. When rectified this will lower our reported rate.
Page | 27

Women requiring a blood transfusion with Caesarean section
Rate is increasing and above national average.
Action Taken:
A 4 year retrospective audit was completed in June 2013.
Notable findings were:
 A high proportion of placental abruptions with significant haemorrhage (there is an
increased risk of abruption in smokers)
 Smoking cessation intervention was not consistently documented
 A significant number of elective repeat caesareans
 Several prolonged labours (associated with fetal distress, need for caesarean delivery,
uterine atony and haemorrhage)
 Medication to prevent uterine atony and haemorrhage not consistently given or
documented in theatre.
In view of these findings the following interventions have been implemented since 2009:
 Smoking cessation intervention for every admission.
 Vaginal birth after caesarean is being encouraged to reduce caesarean rate.
 Breech vaginal births are done in selected cases
 CTG training and documentation for all staff and LMCs to prevent unnecessary caesareans.
 Use of uterotonic in theatre standardised
 Protocol has been introduced for the management of abnormal /prolonged labour.
 Post-partum haemorrhage guidelines reviewed
 Careful assessment of clinical and laboratory findings to ascertain need for transfusion,
which may not always be necessary, even after a significant haemorrhage.
 A Massive transfusion protocol has been developed and implemented.
Although it is difficult to extrapolate trends given our small population, it is very encouraging to see
that only two women were transfused at the time of caesarean in 2012.
National guidelines will be implemented when available, local guidelines are under review.
Page | 28

Women requiring a blood transfusion with vaginal birth
Below national average.
National guidelines will be implemented when available, local guidelines are under review.
An audit to review PPH is also underway (planned for June 2013).

Premature births (between 32 and 36 weeks gestation)
Rate is decreasing and currently below national average.
It was noted in the Maternity Strategic Plan that in 2009 the rate was above national
average, an audit was carried out.
Action taken:
An audit was completed and findings presented at the Perinatal Morbidity Meeting. The
findings are consistent with previously identified high smoking rates of pregnant mothers
(55% of the identified group), contributing to premature birth. A great emphasis has been
directed to the smoking cessation advice and referral aspect (please refer to the Smoking
cessation initiatives from the MQSP).
Documentation of advice/referral was identified as an area for improvement and has been
actioned.
The awareness of the high incidence of preterm delivery rate in Gisborne has driven the
Neonatal Unit to concentrate in optimising the postnatal aspect of care to minimise
morbidities (parent infant bonding, kangaroo care, and support with breastfeeding) and to
reduce the time of separation of mother and baby. A project is underway to provide data to
support the request for more space dedicated to mother-crafting in order to reduce the
Page | 29
length of admission into hospital. Parents have responded well to an integrated model of
care, this offers the opportunity for extensive parenting education in the unit.
The Neonatal unit staff utilises educational tools created specifically for the parents using
the facilities (Rauemi Atawhai: A guide to developing health education resources in New
Zealand was also used for the project).
Support from the paediatric team was gained to offer mothers of premature babies
whooping cough/influenza vaccination (whilst inpatients) in an attempt to contain the
epidemic in the region (this initiative is to be evaluated and will form part of the 2013-2014
plan).
 new or revised multi-disciplinary review processes/meetings that have been coordinated
Multi-Disciplinary Team (MDT)
The MDT Quality Meetings take place on a weekly basis and have been in place since 2009. A review
of all admissions and cases of inductions of labour (IOL), PPH, caesarean sections and clinical
incidents are carried out. The aim is to recognize and acknowledge good practice and identify any
learning needs/actions in a non-threatening environment. Case reviews are focused on the
communication, documentation, cardiotocography (CTG) interpretation and clarity of roles and
responsibilities of all involved. Some cases identified prior to the meeting requiring further
investigation are presented at the perinatal meetings following separate review.
All minutes and action plan and learning outcomes are made available to staff via e-mail, a hard copy
is in the designated area in the office to be read and signed by the staff unable to attend the
meetings.
Quarterly reports are presented at the perinatal meetings and MQSF.
Representatives from other disciplines have also attended; ultrasound, a physiotherapy, newborn
hearing screening.
 changes in clinical practice that have been driven by MQSP initiatives
1. Responsibility of Care:
Introduction of care pathways to ensure clarity about care responsibility (who is responsible at all
times, forms, stamps and care plans), use of SBARR communication tool (Situation Background
Action Recommendation Response) in emergency situations.
2. CTG Training:
FSEP (Fetal Surveillance Education Programme) training in CTG interpretation planned and funded
for all core staff every 2-3 years.
Training took place on the 28th June 2012 in Gisborne; staff who were unable to attend went to the
one in Hastings on 31st May and the 18th October 2012. We will link in to the Regional training.
3. Referral Guidelines:
Workshops were held on the 9th, 14th and 22nd August 2012 with all staff attending one of them.
The purposes of the workshops were to ensure midwives and O&Gs understood service
specifications and responsibilities relating to Referral Guidelines. A report was developed with
recommendations following these workshops and these are integrated in to the Quality and Safety
plan.
Page | 30
4 way conversations are now evident in the Induction of labour Plans (with clear documentation of
who is responsible for the care of the woman at any given time during labour) which can be audited
(implemented in mid-2012).
The Project Coordinator for (Smoking Cessation, BFHI, Safe Sleep and Breastfeeding) has compiled
the postnatal care plan for mother and baby (with clear documentation of who is responsible for the
care of the woman postnatally/transfer to secondary care).
Midwives have all attended documentation workshops in 2012 which includes the importance of
stating who is responsible at all times and documenting this.
Organisational actions requested from Workshops held August 2012 between LMCs and core
midwives regarding:
 Clear identification of who is responsible for the woman’s care at all times
 Grey areas (ongoing clarification required)
 Early discharge (captured by careplans)
 Provision of 24 hour hotel services (further development required)
 Secondary care team (Identified need for core staff to maintain full range of midwifery skills,
further development required)
 LMC as a support person (use of clear documentation of transfer of care including stamps
introduced March 2013)
 Respect and recognition for role of core midwives (Identified benefit of communication and
collegial collaboration from discussion in a safe forum)
 Introduction of Postnatal care plans to identify who is responsible for the woman/baby’s
care
 Introduction of Induction of labour care plans to document and clarify plan of action and
four way conversation
 MDT meeting forum for discussion of IOL and opportunity to clarify gray areas of care that
can be reviewed in a safe forum
 Workshops on documentation (available twice a year, mandatory for all core staff. See
education plan)
 Signature sheet to aid identification of carer inserted in all notes
4. Antenatal diabetes clinic:
A specialist diabetes clinic service has been offered from January 2013. The clinic operates on a
weekly basis. An O&G with special interest in diabetes, a midwife, a diabetes nurse and a dietician
are involved in the service.
5. Newborn Enrolment strategies employed to improve early enrolment:
Action taken:
 Liaison has been in place between NIR Administration and MQSP representative to identify
and improve early GP enrolment.
 Gaps in process identified- maternity and LMCS communicated with.
 Liaising with GP representative to alert difficulties identified (women unaware of named GP)
 Involvement of administrative staff on maternity ward to oversee correction of details
(commenced 7th May).
 2013 data collection will be audited to ascertain number of women not registering correctly.
6. Rural O&G Clinic:
Te Whare Hauora o Ngati Porou monthly rural clinic re-commenced in January 2013 in collaboration
Page | 31
with the TDH O&G and the Hauora midwife.
7. PROMPT:
Prompt has been reinstated.
8. Immunisation:
Training of ANC midwife to vaccinate pregnant women against Whooping cough/Influenza at 28-34
weeks gestation whilst visiting ANC (training completed in April 2013, program started in May 2013)
Whooping cough/Influenza vaccine to be offered to mothers of premature infants.
9. Guideline group:
The multidisciplinary group, which includes a consumer representative, meets on a monthly basis.
Existing protocols and policies are updated and new ones written, these are circulated to all
midwives, obstetricians and other involved parties (such as paediatricians) before approvals.
Maternity Quality Coordinator/Educator has provided intensive input to regional review of policies
and procedures.
10. Infection control:
Change of dose and administration of antibiotics prior to caesarean section, given in theatre (from
May 2012) to optimise time of administration and subsequent therapeutic benefits. There has been
an immediate marked decrease in infection rates following this.
A new infection control initiative to be implemented is the change in procedure for catheterisation
(hospital wide), although no direct link has been found within the maternity department this could
lead to further reduction in infection rates.
11. Maternal Mental Health:
The referral pathway is in place with recommended screening tools for LMCs to use.

communication forums, or networks, that have been established or strengthened and the
quality improvements that have resulted from these
Communication processes
 Dissemination of MQSP information programme to consumers and stakeholders (safe sleep
education/availability of rural O&G clinic/process for compliments/complaints - monthly
feature in TDH newsletter available on TDH website).
 LMC list updated and uploaded to TDH website
 Maternity Services Survey developed and distributed, collection and collation of consumer
feedback planned for the end of July 2013
 Maternity Strategic Plan uploaded to website
Networks/Forums
 Networks have been established or strengthened including:
o Mama and Pepi action group (maternal & child health focus) – cross sector/agency
group
o Our children “Strategy Group/Cross sector – covering continuum of pregnant
women, children and young people
 Presentation of Maternity Strategic Plan and achievements to community agency groups and
TDH Clinical Board
 Whakawhetu workshop 23/24 April 2013 (Cross sector)
 Breastfeeding workshop (in collaboration with Ngati Porou Hauora and Turanga Health) 25
March 2013
Page | 32
Lactation Services:
 TDH received BFHI accreditation for the third time in 2012
 All staff have received lactation education to the required level.
 BFHI, Smoking cessation and Safe sleep project coordinator working as a fulltime equivalent
is a Lactation Consultant and has the ability to be called in the maternity on an as needed
basis.
 A contract for the provision of Lactation Consultant services in the community has been in
place for some time. This contract provides:
o Access to a Lactation Consultant following health professional referral
o An appointment with a lactation consultant (IBCLC) either in your home or in a clinic
setting, with follow up included
o Access to breastfeeding equipment that may be needed
http://www.mamaaroha.co.nz/

We have been privileged to have early access to quality locally produced resources in the
form of the Mama Aroha Talk cards which we have purchased for use by both staff and
clients.
Quality improvement activities undertaken at a Midland regional level
Refer to the Midland Regional Services Plan – Midland Maternity Work Programme 2012/2013
(includes Midland regional progress report as at March 2013).
Examples of Regional Quality Improvement Activities:
 Capabilities/emergency transport (feedback from O&G HoD submitted to region)
 Passport (feedback to proposal to region) – work being completed locally
 Safe sleep (local guideline implemented, feedback to regional proposal and submission of
TDH guideline for consultation)
 Adverse outcome process review
 Consumer/LMC representative framework (regional framework approved)
Page | 33
SECTION FIVE: MQSP STRATEGIC PLAN DELIVERABLES
List of regional and local priorities, deliverables and planned actions for 2013/14
Governance
Priority area
Ensure cultural responsiveness
of all MQSP related activities
Continue to include consumers
in maternity decision making
groups – ensure consumer
input is established at all levels
of maternity services
Surveys include a “women’s
journey” approach
Alignment with regional and
national MQSP
Planned local actions to deliver
quality improvement
Ethnicity data in each initiative/
programme of work will be
captured
Expected outcomes
Measured by
Planned start/finish dates
Improved responsiveness to
vulnerable population
Maori representative
responsible to communicate
and input into MQSP related
activities
August 2013 – June 2014
Close links and positive
relationships with Whanau Ora
Programme
Collaborative and integrative
work programmes (e.g. low
birth weight babies)
Reportable collaboration in
Annual report
July 2013 – June 2014
Iwi stakeholder (Mama and
Pepi) member of the
governance structure
Improved collaboration
primary/secondary care to
improve outcomes for
vulnerable mother and babies
Decisions made inclusive of
consumer view
Report to governance group
MQSF (referral data collection)
Implement the Consumer
Framework in all DHBs in the
Midland region, at the local
governance level
Review survey results and
findings
Maori consumer representation
Appointing LMC representative
for MQSF (contract)
Ensure governance connection
with community sector groups
Collaboration with LMC’s and
Iwi providers
Improved access to care,
collaboration, communication
and ensure actions completed
in stated timeframes
Strong links with community
forums maintained (child
health, immunisation, early GP
Consumers involved in each
DHB’s MQ&SP activities
July 2013 – June 2014
Survey findings are analysed,
and presented at MQSF actions
implemented.
August 2013
Monitored through MQSF
July 2013-June 2014
enrolment)
Ensure annual plan is presented
to consumers and community
sector groups and agencies
Plan is presented
July 2013-June2014
Ensure inclusion of consumers
in planning decision-making and
evaluation of maternity service
Updating current database of
consumers willing to participate
in quality activities and
feedback
Data base updated and
information disseminated
locally
Formally appointing Consumer
representative for MQSF within
agreed framework – Tairawhiti
has a consumer rep
Consumer voice is present in all
discussions and decisions
Feedback from consumers e.g.
focus groups, surveys
December 2013
Appointing core MW for MQSF
Core midwife participation
Core midwife voice locally on
MQSF
August 2013
NZCOM meeting to
recommence in June 2013, rep
to be included in MQSF
Appoint NZCOM representative
Participation into MQSF
August 2013
quality improvement
DHB data regarding number of
women who register by 12
weeks with an LMC is available
and monitored regionally
Expected outcomes
Measured
by
MMAG developing regional
strategies to encourage
consumers to register early
with an LMC
Strategies employed at local
level (for example: GP Liaison
and LMC education to GPs “first
trimester care”, networking
with parenting groups)
MMAG developing Inter Facility
Referral, Transfer and
June 2013 – June 2014
Quality & Safety
Priority area
Improve LMC registration increase number of women
registering with an LMC in their
first trimester
Implement consistent and
robust system for maternity
Improved access to care/ early
intervention
Alignment of provision of
services for first trimester care
(GP/LMC) dissemination of
importance of early booking
Provision of consistent
maternity service
Regional maternity patient flow
policy with sign off by COOs.
Expedient transfers to place of
definitive care
December 2013-June 2014
Page | 35
transfers across Midland and
beyond
Achieve regional quality and
safety efficiencies through
collaboration and sharing -
Capability of each hospital is
agreed so safe repatriations can
occur, maternity transfer
guidelines in place
Reduced number of women
experiencing compromised care
Quality indicators for maternity
transfers developed, standards
for midwifery coordination
developed and implemented to
underpin transfers
Maximise cooperation between
MQSP project coordinators to
reduce duplication and ensure
sharing of work
Improved communication
between midwifery
coordinators
Repatriation Processes,
Guidelines and Standards (to be
localised to TDH)
Evidence of meeting standards
and improved consistency of
care practices
Map of Medicine will be
completed for two areas
identified for improvement and
regional solutions developed
i.e. premature rupture of
membranes (PROM) and
preterm actual / threatened
labour – procedures developed
and added to shared database
(Localised to TDH)
July 2013 - June 2014
Expected outcomes
Measured by
Consistent and supported
maternity education delivered
across region
Midland Maternity Educators
Group are sharing resources,
training calendars, and assisting
with training regionally
Two areas of improvement are
identified from clinical indicator
data and regional solution
developed
Three procedures / pathways
identified, developed and
added to shared database to
improve consistency of practice
across Midland
Quality & Safety (continued)
Priority area
Strengthen consistency of
practices through shared
educational activities maximise collaboration
between Midland regional
midwifery educators
quality improvement
E-learning modules are
developed in collaboration with
GMs HR and e-learning
facilitator
Regional education plan is
developed and activities are
prioritised annually
Regional support for identified
items of maternity education
training equipment
Page | 36
Reduce the smoking and SUDI
rates - support the reduction of
SUDI rates and numbers of
women who smoke in
pregnancy across Midland
All maternity providers have
access to education around
smokefree pregnancy
Progress towards 90% of all
pregnant women entering into
LMC/obstetric care are
assessed using the MoH ABC
programme
Increased focus on smoking
cessation and SUDI prevention
with decreased morbidity of
infants
Increased numbers of pregnant
women accessing quit smoking
programmes
Progress towards 90% of
pregnant women who identify
as smokers at the time of
confirmation of pregnancy in
general practice or booking
with a lead maternity carer are
offered advice and support to
quit
July 2013 - June 2014
All Midland DHBs have a safe
sleep policy in place. A regional
safe sleep policy is developed
and in place
Liaising with Primary Care
cessation coordinator
All providers of maternity
services are trained in
promoting safe sleeping/
breastfeeding and smoking
messages – linked to Regional
and local programme
Midland regional support
through the purchase of pepi
pod safe sleep devices
Priority area
Ensure improvements
undertaken in alignment with
PMMRC recommendations
(TDH specific focus)
quality improvement
Early screening in pregnancy;
diabetes, smoking, family
violence, sexual health, new
born hearing screening
Expected outcomes
Measured by
Screening rates and processes
are improved
Measure and monitor through
MQSF
July 2013 – June 2014
Early GP enrolment
GP enrolment rates are
improved
Monitor through Child & Youth
Health Compass response and
MQSF
July 2013 – December 2013
Evaluate the maternal mental
health referral pathway
Referral pathway clear to all
practitioners involved/
Data collection, audit at all
points e.g. LMC/primary
April 2014
Page | 37
refresher workshops
care/NGO/secondary care
Develop strong linkages and
close the loop between all
Quality forums and quality
activities such as RCA
recommendations, incident
analysis
Maintain high standard of
existing processes (MDT,
Perinatal meetings) to review
cases, disseminate outcome
action points.
Ensure learning’s embedded in
to practice
Strengthen appraisal system
Number of actions/learning’s
implemented into practice
changes. Presentation to MQSF
quarterly.
July 2013 – June 2014
Dissemination of PMMRC
recommendation on transfer of
care for multiple pregnancy
Prevention of maternal and
perinatal morbidity and
mortality
Data collection
June 2013 – July 2014
Detection of fetal growth
restriction
Offer early specialist
consultation
Dissemination of PMMRC
recommendation through
MQSP established channels and
data collection
Antepartum haemorrhage
Close monitoring for foetal
growth and pre-term birth
Continue close collaboration
with sonographer to ensure
significant discrepancies are
monitored and quality of
service provided improved
Develop a process for support
and counselling for bereaved
parents.
Process developed for early
intervention
Investigate process to obtain
post-mortem consent to ensure
wider whanau is involved
Education of parents of SUDI
prevention
Monitored through MQSF and
Perinatal meetings
Access to perinatal
investigation and supporting
parents
June 2013 – July 2014
June 2013 – July 2014
June 2013 – July 2014
June 2013 – July 2014
Page | 38
Collaborate with Social Work
service to develop this process
Investigate reasons for
perinatal death
Priority area
Develop improved clinical
pathway to reduce incidence
th
and improve outcome of 3-4
degree tears
Develop process for debriefing
following traumatic deliveries
(consumer led)
quality improvement
Clinic at 6 weeks following
repair of 3-4th degree tear
Referral to physiotherapy
department following repair of
3-4thdegree perineal tear
Follow up at 6 weeks to debrief
on traumatic births/ repair of 34th degree tear - consumer
voice
Expected outcomes
Measured by
Improvement of repair
documentation and outcome /
education
Audit/Evaluation of service
provided in collaboration with
physiotherapy department
July 2013-June2014
Improve multi-disciplinary
approach and health outcomes
Included in the consumer
survey
Process to be developed with
consumer input
Evaluation of service provided
(follow up questionnaire)
Audit follow up of outcome of
consumers experiencing
traumatic birth events
July 2013 – June 2014
Expected outcomes
Measured by
Information to direct
recommendations about how
many/what sort and where P+P
classes need to be held
All maternity providers have
access to education around
smokefree pregnancies
September 2013 – June 2014
Align with service specification
review include antenatal
education to target vulnerable
Initiatives are undertaken to
meet identified low attendance
in pregnancy and parenting /
Service Delivery
Priority area
Improve attendance at
pregnancy and parenting
classes especially for rural and
Māori pregnant women increase number of pregnant
women who enrol in pregnancy
and parenting (P+P) / antenatal
classes, especially in rural areas
Align with PMMRC
recommendation to promote
antenatal education
quality improvement
Identify existing classes
available, costs, attendance and
location
Information from the Hapu and
iwi services in Tairawhiti
Wananga Evaluation is utilised
as basis for action plan to
increase attendance rates for
Māori women
Implement recommendations
from consumer group surveys
in rural areas
Page | 39
pregnant group. Develop plan
Support framework for young
vulnerable women who are
pregnant - develop a regional
programme to address
identified issues and provide
relevant support
Include vulnerable pregnant
woman group in MQSP
(Group exists in Tairawhiti)
Stocktake of local services
provided (awaiting completion
of MoH review)
Identify key stakeholders and
gaps
Close collaboration with
coordinators and iwi providers
to support young women
Representative of group to
report to MQSF governance
group
antenatal classes
Review of current services, data
collection
Young vulnerable women who
are pregnant have improved
access to information, support
and quit smoking programmes
Provision of action plan in place
for mother and baby through
the pregnancy labour and
postnatal period
Collaborative work with
primary providers and PHOs
towards developing a regional
programme for young
vulnerable women who are
pregnant.
Collaborative work with local
agencies, mama and pepi action
group and vulnerable pregnant
woman group
June 2013 - June 2014
July 2013 – June 2014
Further develop roles and
linkages of Vulnerable Pregnant
Women Multi-Disciplinary
Group
Monitored through MQSF
Measure achievements in child
and youth compass response
Q1 & 2
quality improvement
Regional dashboard for
maternity clinical indicators is
developed and updated
Expected outcomes
Measured by
Current regional data is
available to shape direction of
care and action
The availability of
comprehensive regional data
July 2013 – June 2014
Audit list planned (see appendix
4)
Audit finding to guide practice
improvement
June 2013-June 2014
Identify breastfeeding rates in
Improved access to consistent
Document developed to share
with all stakeholders. Local data
is presented regularly to MQSF
Enhanced availability of
Research and Evaluation
Priority area
Regional data availability comprehensive data collection
systems to enable regional
benchmarking and reporting
Local data available to identify
areas for improvement
Improving breastfeeding rates
Accurate regional information is
available which identifies
issues, trends and enables focus
for regional initiatives
Page | 40
through use of agreed regional
tools - regional agreement to
the networking and sharing of
resources throughout Midland
re breastfeeding
Midland using regional BFHI
data
breastfeeding information
Explore the development of the
use of IT applications to
improve access to information
for Māori and disadvantaged
mothers
Consistent provision of support
and advice, lactation
consultancy service review
breastfeeding resources in the
Midland region and the sharing
of initiatives and resources
through the regional
Breastfeeding/BFHI sub group
Regional support for the
purchase of Mama Aroha
breastfeeding resources for
each of the Midland DHBs
Breastfeeding rates (TDH
already does this)
Continue collaboration with
primary and secondary care,
promote and support staff
education
Benchmark Regionally and
Nationally
Audit referrals to Lactation
Consultant Services (Tairawhiti)
Audit Tongue Tie and referrals
to LMC (Tairawhiti)
Enablers / Support
Priority area
Workforce intelligence - plan
for a sustainable maternity
workforce (especially in rural
areas)
quality improvement
Head count to service current
population vs. workforce
needed for future birthing
trends is identified
Expected outcomes
Measured by
Understanding of current state
and future state needs to
achieve sustainability
Workforce plan and outcomes
December 2013 – June 2014
December 2013 – June 2014
Areas of shortage are identified
Accurate baseline data and
engagement of service
providers in developing
innovation solutions
Local solutions are achieved
with links to region
Identify rural midwives’ issues
and work towards regional
solutions
Trends in LMC and secondary
midwifery workforce numbers,
Local involvement sought
through process
Workforce plans in place locally
– linked to region
Page | 41
distribution and forecasting are
analysed by regional workforce
group
Use IS technology to improve
information sharing - improve
access to information between
LMCs and with consumers
Implement national maternity
client information system (TDH
first adopter in NZ)
Utility of existing workforce
model critiqued against
workforce forecasting (includes
midwives and O&Gs)
Web portal for LMCs and
consumers in place
Application development for
LMC and consumer smartphone
use explored
Work with regional IS to
develop implementation plan
Review local clinical and
business processes across
women’s journey
Increased access to information
for consumers and LMCs
Shared electronic space open to
LMCs and consumers to access
information
Users of the system provide
feedback to influence system
development
Training in place
November 2013 “Go Live” in
Tairawhiti DHB
Ensure immediate practice
improvements where required
Transition from current process
to electronic process completed
Plan implemented
Participate in MCIS system
development at the national
level, working with the clinical
reference group and CleverMed
(TDH has in progress)
Implementation plan
commenced in early adopter
site (Tairawhiti)
ACRONYM KEY:
MQSP
CCM
MSQF
MEQC
= Maternity Quality and Safety Programme Project Coordinator
= Clinical Care Manager Women, Child and Youth
= Maternity Services Quality Forum
= Midwifery Educator and Quality Coordinator
NPH
= Ngati Porou Hauora
TH
= Turanga Health
CDO&G = Clinical Director Obstetrics and Gynaecology
BFHI/SC = Baby Friendly Hospital initiative /Smoking Cessation/Safe
Sleep Project Coordinator
Page | 42
NMMG = National Maternity Mortality Group
MIS
= Maternity Information System
PMMRC = Perinatal Mortality Morbidity Review Committee
Regional Priorities
MMAG = Midland Maternity Action Group
LMC
= Lead Maternity Carer
O&Gs
= Obstetricians & Gynaecologist
Local Priorities
Measures:
 Increasing number of women registering with an LMC by 12 weeks by 2016
 Implementation of the Maternity Quality and Safety programme, and reporting of regional and local activity relating to this
 Progress towards 90% of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking
with a lead maternity carer are offered advice and support to quit.
 All DHBs in the Midland’s region have in place a Safe Sleep Policy
 Collaborative work with primary providers and PHOs towards developing a regional programme for young vulnerable women who are
pregnant.
NOTE: All measures reported are broken down to include ethnicity, age and rural/urban domicile.
Page | 43
Appendices
Appendix 1 Midland Regional Services Plan – Maternity Work Programme 2012/2013 (including detail on regional progress as
at June 2013)
Notes:
- MMAG= Midland Maternity Action Group;
- Activities highlighted in red italics are locally led and funded. The remaining activities are to be led, funded and completed regionally.
Midland Regional Services Plan – Maternity Work Programme 2012/2013 (including detail on regional progress as at June 2013)
Key themes/Project
Team/Timeline
Governance
Maternity quality committee in
place in each DHB
MMAG
December 2012
Actions to deliver improved
performance
Measured by
Outcomes
Midland Regional Progress
Report as at June 2013
Maternity Quality Committees
established
Quality committee in place in
each DHB
Standardised TOR agreed
Communication structure
between national, regional and
local governance groups in
place
Reporting requirements met
Communication processes
effective
Committee oversees and
ensures coherence of all
maternity quality and safety
activities
Terms of Reference developed
and re-visited by MMAG in Feb
2013. Regional outcomes and
communication will be
improved through the
reconfiguration into sub groups,
such as, Maternity Educators &
Midwifery Leaders sub group,
LMC sub group, SMO sub group,
MQSP coordinator sub group,
and Breastfeeding/BFHI sub
group, etc.
MMAG and the Maternity
Educators & Midwifery Leaders
Groups meet quarterly; MMAG
members are responsible to
disseminate information to
their local DHB multidisciplinary teams and feedback
into the MMAG regional
consultative process. Other
meetings are called, as
Page | 44
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
required.
TORs for the sub groups will be
developed and submitted to the
May 2013 meeting of MMAG
for consultation.
Nexus – an online, secure
communication web ‘space’ is
used to work collaboratively on
projects across the Midland
region, meeting agendas,
minutes and documentation are
regularly uploaded to Nexus.
MQSP coordinators have been
included in MMAG
membership.
National communication is
received and actioned both
locally and regionally.
Maternity Strategic Plan
MMAG
May 2012
Maternity Strategic Plan
developed
Plan approved
Plan guides future decision
making regarding regional
maternity services
Consider and, where
appropriate, support
implementation of
recommendations from
national bodies such as the
Perinatal and Maternal
Mortality Review Committee
Progressing
The Midland Regional Services
Plan 2013-2016 (draft) includes
the Midland Regional Maternity
Work Programme for the
period July 2013-June 2016.
Final draft due to go to Midland
DHB boards on 13 May for sign
off, prior to submission to the
Ministry of Health.
Page | 45
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
(PMMRC) and the National
Maternity Monitoring Group
(NMMG)
The Midland Maternity Work
Programme has been
developed by MMAG, in
consultation with Maori Health,
Health Workforce, IS and at a
DHB executive level.
The work programme is guided
by the recommendations from
national bodies, such as the
PMMRC and the NMMG.
Maternity Annual Report
Maternity Annual Report
complete
Template developed
Final report accepted/approved
Report guides future
developments/RSPs/APs
MMAG
June 2013
Progressing
HealthShare developed a
template prior to receipt of the
MoH guidance on Annual
Report development. A revised
Annual Report template has
been developed and circulated
for use by the Midland regional
DHBs.
Progressing
Quality and Safety
Implement the National
Maternity Quality and Safety
Programme
MMAG
June 2013
Programme implementation
plan developed and agreed
Standardised templates
developed to ensure:
Standardised formal review
processes for serious and
sentinel events are in place
Standardised evidence-based
clinical case review processes
are in place
Representation of communitybased clinicians and consumers
Programme in place in all 5
DHBs
Mechanisms in place to
evaluate systems and processes
Standardised templates have
been developed as follows:
Midland regional policy:
‘Adverse Obstetric Outcomes:
Monitoring, Case Review,
Serious and Sentinel Event
Requirements and Processes’
(draft)
The Midland Maternity
Educators & Midwifery Leaders
Page | 46
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
in the formal and informal
review processes to ensure their
perspective is considered.
Defined processes in place to:
implement changes in clinical
practices
reduce unnecessary variation in
clinical practice
define and strengthen clinical
pathways
influence local service delivery
planning and policy
Implement the National
Maternity Standards
MMAG
June 2013
Standards implementation plan
developed and agreed
Standardised templates
developed to ensure:
MDT meetings in place
Annual report complete
LMCs, consumers and other
community/hospital -based
maternity practitioners/
stakeholders are involved in
All Standards are met
evaluate achievement against
the standards
group has been tasked with
progressing the draft templates
for submission to MMAG for
consultation and approval.
Members of MMAG are
submitting the draft template
to their local DHB Quality & Risk
and Serious & Sentinel Events
Review Committees for
consultation and feedback to
MMAG.
HealthShare is to look at the
possibility of developing a
Midland regional policies,
procedures, guidelines and
templates repository for
documents developed through
the Midland clinical networks. A
document control process will
also be developed.
Secure access may be via local
DHB users ‘linking’ to the
regional policies through their
own DHB’s controlled policies
library
Progressing
MMAG has developed a
‘Midland Region Consumer
Representative and LMC Liaison
Representative Framework
(draft)’ and is in a consultative
phase. Awaiting decision from
regional GMs Human Resources
on appropriate honorarium for
Page | 47
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
appropriate forums
RSP Māori Accountability
Framework
Deliver upon the standards of
the RSP Māori Accountability
Framework
Evidence of performance
against standards and
associated measures as
indicated in the RSP Māori
Accountability Framework
Regional resource in place
Meaningful Māori participation
on all workgroups associated
with this plan
evaluate achievement against
standards
All standards are met
Cultural responsiveness KPIs
established
Education sub-group formally
established and action plan
developed and implemented
Facilitation of the education
sub-group to support increased
number of educational
initiatives available across the
region including:
Face to face foetal surveillance
training
Epidural recertification
Return to practice pathway
Regional training supervisor
network
Review of regional educational
resources and development of
resource library
Identified E-learning modules
Access to maternity education
increases on 11/12
Regional template developed to
meet Midwifery Council
requirements
MMAG and associated
workgroups
June 2013
Explore opportunities for
shared educational activities/
initiatives
MMAG Education sub-group
Regional Training Network
June 2013
LMC reps and consumer reps.
Progressing
MMAG membership includes a
representative from Te Puna
Oranga (Waikato) and
represents Midland Maori
Health Services. Te Puna
Oranga may be in a position to
undertake a service
responsiveness audit in 2014.
Cultural workshops are
incorporated into the
professional requirements of
staff in each of the Midland
DHBs.
Progressing
MMAG’s Maternity Educators &
Midwifery Leaders sub group is
leading the regional work on:
Face to face foetal surveillance
training compliance
Epidural recertification
Return to practice pathway
(incorporated into the ‘Midland
DHBs Regional Midwifery
Passport’ (draft) – to be
reviewed by Midland H&S and
HR managers)
MFYP (a robust
framework/pathway for new
midwifery graduates)
A stocktake of regional
education resources has been
undertaken and a list of
Page | 48
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
Identify the “top ten”
policies/guidelines and
standardise regionally
Lippincott Manual reviewed –
guidelines for review agreed
and action plan developed by
Guideline subgroup
Facilitation of the guideline subgroup to ensure:
Guidelines/policies are evidence
based
Guidelines/policies are
communicated and
implemented
Ten policies/guidelines
complete and implemented
across the region
MMAG Guideline sub-group
June 2013
essential equipment/resources
developed. Approval will be
sought from MMAG at its May
2013 meeting to the purchase
of items of educational
resources.
A learning package has been
identified using e-learning
modules. These have been
added to the e-learning
platform.
Progressing
MMAG has identified 12
policies/guidelines for the
Midland region. These are in a
consultative phase and will be
further developed by the
Midwife Educators & Midwife
Leaders sub group of MMAG:
Management of Ante Partum
Haemorrhage (includes
placenta praevia and abruption
placenta)
Anti-D Immunoglobulin
Administration
Electronic Fetal Monitoring
Fetal Fibronectin as a Screening
Test for Pre-Term Birth
Management of Hyperemesis
Gravidarum
SBARR/ISOBAR/ISBARR
Communication Tool
Management of Menonium
Stained Liquor
Page | 49
Key themes/Project
Team/Timeline
Service Delivery
Develop a regional neonatal
and maternity emergency
response plan
MMAG
June 2013
performance
Measured by
Outcomes
Management of Shoulder
Dystocia
Vaginal Birth After Caesarean
Water Immersion During
Labour and Birth
Maternity Retrieval Team
Standards and Competencies
Policy: Safe Infant Sleep
A ‘Regional Maternity
Procedure Development
Process’ has been implemented
to assist with the pathway for
regional policies and guidelines
to progress from draft to final
status
It is likely that these regional
policies/ guidelines will be
placed on a Midland regional
web based document
repository
Progressing
Regional neonatal and
maternity emergency response
plan developed and
implemented
All stakeholders involved in
plan development
Escalation plan for resource
shortages included
Plan links to regional transport
project
Plan communicated to all
maternity providers
Emergency response plan in
place
Mechanism in place to
audit/evaluate communication
between providers in cases of
clinical emergency
A ‘Regional Neonatal and
Maternity Emergency Response
Plan (Guidance and Templates)
DRAFT’ has been developed by
MMAG. However, consultation
has highlighted the need for a
Maternity Escalation Plan for
the Midland region when
shortages in resources are
experienced, such as staffing or
NICU cots.
A Midland Regional Escalation
Page | 50
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
Plan was identified as a need in
the February 2013 MMAG
meeting and is in development
A ‘Midland Regional Maternity
Services: Inter Facility Referral,
Transfer and Repatriation
Processes, Guidelines and
Standards’ (draft) has been
developed and is in a
consultation phase. Midland
DHBs are providing detail on
their capability for repatriations
Progressing
Integrated pathway developed
for two maternity/ obstetric
conditions
Guideline sub-group identify
and develop pathways
Facilitation of the guideline subgroup to support:
Current best practice used to
drive development
stakeholders involved in
pathway development
Two Pathways developed and
implemented
Mechanism in place to evaluate
compliance/success
MMAG has developed two
pathways (in draft):
Midland Regional Threatened /
Actual Pre-Term Labour
Pathway – Map of Medicine are
currently working on
transferring the information to
a MoM Pathway
June 2013
Midland Regional Maternity
Services : Inter Facility Referral,
Transfer and Repatriation
Processes, Guidelines and
Standards
It is likely that these regional
policies/ guidelines will be
placed on a Midland regional
web based document
repository
Progressing
Page | 51
Key themes/Project
Team/Timeline
Stakeholders are
involved/engaged in all service
development activities
performance
Process in place to ensure
stakeholder involvement/
engagement
Measured by
Outcomes
stakeholders are involved in
service development activities
and improvement
Feedback is obtained on local
consumer experiences of
maternity services
Process implemented
Consumer survey developed
/implemented as per national
agreement
Review clinical indicators and
establish what is already
collected/where
Ensure regionally consistent
approach to data collection and
reporting
An overview of local maternity
demographics and outcomes is
available
Information in the New Zealand
Maternity Clinical Indicators
report is disseminated to
Programme in place in all five
Midland DHBs
evaluate information/ reporting
June 2013
Research and Evaluation
Develop consistent and aligned
data collection systems and
standards to enable regional
benchmarking and reporting
against the national maternity
clinical indicators
MMAG provides support to the
New Zealand Institute of Rural
Health in the Midland region
rural maternity services
consumer consultation. It is
anticipated that the report will
be published in September
2013. Findings from this
research will inform MMAG’s
service development initiatives
within maternity and LMC
services for consumers.
The views of rural consumers
will be sought from initial
enrolment with an LMC /
obstetric provider, through
antenatal education (if any),
labour, delivery and the first six
weeks following delivery
MMAG as a clinical network has
a presence on the HealthShare
website, hosted via Waikato
DHB. This enables transparency
of the MMAG members
representing the regional
maternity work
Progressing
The HealthShare Data Analyst
will provide quarterly maternity
data reports and work with
MMAG to provide the
information the group is
interested in analysing. Service
Page | 52
Key themes/Project
Team/Timeline
MMAG
June 2013
Consistent approaches to audit
and evaluation are developed
MMAG with DHB Audit teams
June 2013
Enablers / Support
Explore opportunities for a
shared regional patient activity
repository
MMAG
June 2013
performance
Data presented locally and
regionally to allow for local and
regional approach to service
improvement where
appropriate
Current audit/ evaluation
activity reviewed and regional
schedule agreed
Regional patient activity
repository in place
Measured by
Outcomes
maternity clinicians and other
relevant stakeholders
Collection of consistent and
comprehensive primary
maternity data occurs,
regardless of the provider of
primary maternity care
Data/information used to
prioritise quality improvement
activities
Processes to audit and improve
the quality of maternity data
collection, storage and
reporting are in place
Audit/evaluation templates
developed for agreed areas
improvements will be achieved
through this evaluative and
informative reporting.
The HealthShare Data Analyst is
in discussions with the MoH’s
Data Analysts to seek the
release of unofficial annual data
to assist regional service
improvement initiatives
Progressing
Template and schedule agreed
and implemented
Template development and
scheduling of audit/evaluation
activity to be completed prior
to June 2013.
To be commenced May 2013
Regional understanding of
current patient activity and
associated costs
Regional approach to
developing future demand
scenarios based on regional
growth/ demo-graphics, etc.
Impact analysis of different
models of care from a regional
perspective
HealthShare’s Data Analyst will
provide Maternity Reports to
MMAG meetings so that areas
of opportunity can be identified
through the use of data.
Discussions are currently being
held with the MoH’s Data
Analysts to seek the timely
release of data to assist
regional analysis and
improvement initiatives. The
shared regional patient activity
repository requires Midland IS
input and therefore is reliant on
Ability to consolidate and
compare patient
activity/information across the
five DHBs
Page | 53
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
Explore opportunities for a
web-based shared
communication/ information
sharing tool
MMAG with Regional IT
Manager - June 2013
Shared electronic
workspace/tool in place
Mechanisms are in place for
discussion and dissemination of
data, guidance or guidelines,
innovative practice, new
research, and local initiatives to
community-based maternity
practitioners/stakeholders
Programme in place in all 5
DHBs
IS resourcing and planning.
MMAG (via HealthShare) is
supporting the New Zealand
Institute of Rural Health’s
maternity consumer
consultation. The aim of the
consultation is to establish
whether maternity services in
the Midland region fulfil the
perceived or actual needs of
rural women. Focus groups and
individual interviews, supported
by a brief demographic
questionnaire, will be the
method used. Ethics approval is
currently being obtained and it
is anticipated that the report
will be published at the end of
September 2013. MMAG will
use this report to identify
service improvement initiatives
to improve models of care for
women in the Midland region.
Progressing
Consideration has been given to
the use of mobile apps. to assist
in the transfer of information
and communication between
LMCs and consumers. Note: any
web based shared
communication information /
sharing tool will need to be in
line with the Midland regional
IS developments.
Page | 54
Key themes/Project
Team/Timeline
performance
Measured by
Outcomes
Nexus provides a shared webbased communication /
information sharing tool and
this is utilised by MMAG to
progress collaborative work
across the region
Progressing
Page | 55
Appendix 2 Terms of Reference – MQSF
TERMS OF REFERENCE
MATERNITY SERVICES QUALITY & SAFETY FORUM
PURPOSE







To support the Service, the Tairawhiti District Health (TDH) Clinical Board and multidisciplinary
clinical teams to monitor and manage standards of clinical care to ensure they are of a high
quality
To require, support and facilitate formal clinical governance and clinical practice improvement
processes in Tairawhiti DHB
To monitor and review systems, standards, indicators and outcomes which reflect the quality of
clinical care provided within the service
To monitor and oversee regional and local activities associated with:
o The National Maternity Quality and Safety Programme
o The National Maternity Standards
o Maternity Service Specifications
o Section 88 (Referral Guidelines)
To provide a forum in which decision making and responsibilities for the quality of care are
shared between clinicians and managers
To report these activities to the TDH Clinical Board
To manage the risks of care
STRUCTURE
Regional:
Local:
Page | 57
CONSTRAINTS
 The Forum must act to support Organisational and Service goals
 The Forum must uphold compliance with legislative and standards requirements as well as
contractual obligations.
 Legislative responsibilities for action may lie outside the delegated authority of the Forum and
its members. Issues of this regard must be clearly documented in communication to those who
hold the responsibility to act*
 Forums will escalate issues beyond their authority to TDH Clinical Board or relevant Clinical Care
Manager (CCM) or Clinical Director (CD) of Women Child & Youth (WCY) in the first instance
 Forum activities must support the Organisational and Service Risk plan
CHAIRPERSON
 CCM/WCY
REPORTS
 Annual Report submitted to TDH Clinical Board annually.
 Reports of Clinical Governance and Quality Improvement activities conducted by Service
multidisciplinary clinical teams will be reviewed by the Maternity Quality Forum. These activities
may include but are not limited to:
o Serious Event Reviews
o Morbidity and Mortality reviews (Perinatal reviews)
o Clinical Audit
o Peer Review and Appraisal
o Clinical Practice Improvement activities
o Protected Quality Assurance Activities (PQAAs) – e.g. (Case review from Adverse
event)
o Incidents and Complaints
o Clinical Indicator Review
o Retrospective Clinical Record Review
o Development and achievement of Service Risk plans




Maternity Service Quality Coordinators and Educator or equivalent roles TDH will provide
reports to the Forum on Service incidents, complaints, Serious Event Reviews, Health and
Disability Commissioner’s (HDC) reports, Accident Compensation Corporation (ACC) reports,
Occupational Health and Safety (OH&S) issues and patient satisfaction surveys
Recommendations and Actions from the Maternity Quality and Safety Forum will be actioned by
relevant Forum members
Appropriate items will be escalated to the TDH Clinical Board and the CCM/CD in the form of a
risk plan for their consideration
Information and direction will be communicated to multidisciplinary clinical teams through
relevant members of the Maternity Quality and Safety Forum (Discuss wha issues flagged to
Clinical Board)
OBJECTIVES AND PRIORITIES
The broad objectives for the Maternity Quality and Safety Forum are to:
 Oversee all quality improvement, quality assurance and risk management activities within the
Maternity Services
 Oversee the Service Risk Plan and the strategies to achieve the deliverables in this plan
 Priorities for the Forum as determined by the Board of Clinical Governance (DHB specific) will be:
o Serious Event Reviews
o Clinical Indicator Reviews
Page | 58
o
o
o
o
Review of other Incidents and Complaints
The National Maternity Quality and Safety Programme
The National Maternity Standards
Maternity Service Specifications
Specific objectives of the Maternity Quality and Safety Forums will include the following:
Consumer involvement
 To encourage consumer participation and engagement in order to maintain and improve the
quality of care provided by the Service. Consumer representative will disseminate to key
consumer representative group as agreed by Forum.
 To receive a regular report on complaints, patient satisfaction surveys, ACC and HDC reports
 To feed back on these reports to multidisciplinary teams through clinical quality forums
Clinical Quality Evaluation and Improvement
 To review outcomes of Serious Event Reviews and Root Cause Analysis (RCAs). To endorse
and monitor implementation of Serious Event Review panel recommendations. To table RCA
recommendations and actions.
 To monitor and analyse trends from incident reporting and make recommendations to
reduce recurrence of incidents (corrective action)
 Ensure that all clinical policies, procedures and guidelines of the facilities regarding the
provision of maternity services are developed, reviewed or updated through
multidisciplinary consultation within prescribed time frames.
 Review quarterly women’s compliments and comments, and Customer Satisfaction Surveys,
face to face or phone feedback and suggestions, and propose changes/ implement actions as
necessary/appropriate.
 To review outcomes and recommendations from Morbidity and Mortality reviews and to
endorse and monitor implementation of these recommendations
 To set audit priorities and schedules. To review audit outcomes. To endorse and monitor
implementation of audit recommendations
 To monitor Peer Review and Appraisal
 To monitor Clinical Practice Improvement activities
 To monitor Retrospective Clinical Record Reviews
 To monitor and review Clinical Indicator reports
 To review the key areas for improvement and make recommendations for change through
clinical quality forums
 To monitor service specific requirements issued by the Ministry of Health
Clinical Risk
 To review clinical risks as defined in the Service Risk Plan
 To oversee Protected Quality Assurance Activities for the service and ensure bi-annual
reports are made to the Ministry of Health
 To identify appropriate methods to correct, eliminate or reduce identified risks
 Maternity Quality and Safety Forum members are to disseminate recommendations to
clinical quality forums
Page | 59
Professional development and management
 To promote opportunities for professional development which support excellence in clinical
care
 To monitor professional development and the maintenance of professional standards
 The Maternity Services Quality and Safety Forum will ensure that an annual Continuing
Education and Quality Plan is available for all Maternity and Neonatal Practitioners. An
annual report of education will be available to the Maternity Services Quality and Safety
Forum by the end of January. This needs to link in to organisational training plan and
Women Child & Youth Service Plan.
FREQUENCY OF MEETINGS
 Monthly
MEMBERSHIP
The membership of the Forum must be multidisciplinary and have sufficient authority to require
change within the service when required.
Core members:
 Clinical Care Manager Women, Child & Youth (Chair)
 *Clinical Midwife Manager (Vice Chair)
 *Clinical Director Obstetrics
 *Clinical Director Paediatrics
 *Clinical Nurse Manager NNU
 NZCOM representative
 *Lead Maternity Carer (LMC) representative
 Midwifery Educator
 *Consumer Representatives (Maori, Pacific Island)
 *Core Midwife
 Maori Midwife representative
 Quality Co-ordinator NNU
 Project Coordinator: BFHI, Smoking Cessation, Safe Sleep
*Denotes members that must provide a delegate if not available to attend.
Members for minutes/occasional attendance as possible:
 Consultant Obstetricians
 Consultant Paediatricians
 Te Puia Springs Midwives
 Clinical Director Anaesthetics
 GP Liaison
QUORUM
Not less than 50% of the core membership plus the Chair or Vice Chair (13 core members) =
minimum of 5 plus chair/vice chair. If a quorum is not achieved, the meeting may go ahead but
decisions and recommendations will be emailed to all members for agreement, progression and
action prior to next meeting.
The committee has the power to co-opt relevant individuals as identified as necessary for decision
making by the committee. The committee may invite other individuals for a specific meeting/s, or
part thereof, where it is considered necessary for decision-making.
Page | 60
REVIEW DATE
 Forum role and terms of reference to be reviewed annually
 Subsequent review date to be determined on this date.
RESOURCES
 Forum Secretariat services are to be provided by an administrator from within the service.
 The Service Quality Coordinator or designated role (DHB specific) will be responsible for
coordination of standing and ad hoc reports and analysis of these (as outlined in Section 5. of
these Terms of Reference) and facilitating follow up on action points, as directed by the Forum.
FOOTNOTE:
“Where the Forum considers a clinical activity which is covered by regulation or legislation, the
responsibility for actions may lie outside the Forum members. Such responsibility shall be clearly
identified in Forum minutes and / or communication to the relevant Tairawhiti DHB manager or staff
member Note that the Forums act on the basis of their advocacy and the delegations implicit in their
membership but when they are confronted with Issues of significance which cannot be resolved
through implicit delegations, they will escalate to the relevant management of
DHB. Recommendations arising from legislative and/or external compliance reviews are particular
examples of requirements that may exceed delegations.”
“Maternity Services Quality and Safety Forum members shall be aware of confidentiality issues.
When a sensitive item is being discussed, the Chair shall identify it as an ‘in committee item’, on the
agenda and the issue should not be discussed outside of the meeting unless released at the meeting
by way of resolution.”
Authorised By
Maternity Services Quality & Safety Forum Chair
Authorised By
Clinical Director
Terms of Reference Drafted:
Terms of Reference Reviewed
Terms of Reference to be reviewed:
December 2012
December 2012
Annually
Page | 61
Appendix 3 Maternal Mental Health Referral Flowchart
Page | 62
Appendix 4 Audit Schedule for Maternity Services 2013
2013
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Babies born at 32-36+6 wks. gestation
Standard primiparae sustaining a 3rd or 4th degree perineal tear and no
episiotomy
Transfer of care documentation
LSCS with blood transfusion during same admission
√
√
√
√
PPH
LSCS under a G.A
Record keeping
Betamethasone administration
Tongue Tie
√
√
√
√
√
Appendix 5
Maternity Services Survey
Page | 65

Maternity Services Annual Report 2013

Transcription

Similar documents

The Bread and Roses Strike - Canadian Union of Postal Workers

presentation ( format)

guardian news - ISO Quality Services Ltd

Out of Season - Essex Maternity Wear

This adorable Hollywood insider—she`s been a

of pregnancY treats

A BAftNfS HWpwt

Maternity Clothing and the SCA

Femininity, Masculinity: The Internet Usage of Women on Maternity

The Growth of a Brand Liz Lange and the World Categories Now