Leading change

The Midwifery Matrons at Northampton General Hospital NHS Trust (NGHT) led on service development to address unwarranted variation in practices identified in complaints being made to the midwifery team. This has led to improved experiences and better use of resources within the Trust.

Where to look

The Midwifery Matrons noted when addressing women’s complaints that many of the issues raised by them could have been avoided had communication been better. In particular women’s concerns could have been addressed earlier by having detailed care plans before the birth of their babies and/or by holding face–to-face meetings following the births. This would have improved care and communication. Although there weren’t similar services locally, the Matrons utilised the evidence base to support implementing changes which demonstrated how true compassion involves listening, making ourselves available and being able to do something about what we hear (Kirkham 2015).Through devising a clinic model which enabled a woman to discuss any aspects of her care, the matrons felt they could address unwarranted variation seen in care planning and communication.

What to change

Prior to the change the Matrons were seeing women on an ad hoc basis when concerns had been escalated to them. So weren’t able to address all concerns in a systematic way. This unwarranted variation in management of complaints, care planning and communication were the focus of the change. The team felt addressing these would provide better patient experiences and outcomes. The formalising of the clinic model with allocation of dedicated time to see women was better from a time management perspective; it ensured that the time spent with women was proactive, as opposed to reactive.

The ‘Meet the Matron’ clinics were set up to give every woman the opportunity to establish and receive good communication as well as identify and address variations in practice.

How to change

The Midwifery team devised a clinic model and a running schedule. They promoted the new ‘Meet the Matron’ clinics via flyers in GPs surgeries, Children’s Centres and all women postnatally at the hospital. The new service was promoted to all women to ensure everyone has the opportunity to discuss with the midwives any issues and concerns they may have. The clinic was highlighted to all members of the multidisciplinary team who referred women to them as well as women referring themselves.

Managed by two Midwifery Matrons, a day clinic runs weekly with an average of 40 women attending every month. The focus is upon these key areas of care:

• Choices- At times some women may request care outside of guidance. This clinic gives the opportunity for women to be heard, with the matrons acting as advocates putting a robust plan in place with the women at the heart of care.
• Concerns- Any women/partners who are unhappy with any aspect of care are given the opportunity to ‘Meet the Matron’ in the clinic or home where their concerns can be listened to. Their comments are then acted upon and many changes have been implemented as a result of listening to this feedback.
• Closure- For women who consider their birth traumatic, they are given the opportunity to debrief and discuss the birth, have questions answered. One of the Matrons is trained to treat birth related Post Traumatic Stress Disorder (PTSD), which is known to affect at least 10,000 women in the UK per year. There is no time limit for this service.

Midwives and student midwives sit in and observe the clinics to help develop their communication skills.  This empowers them to have the conversations when women ask to go against advice in relation to birth.

The Matrons act as advocates for the women and partners. They provide contact numbers so they can be contacted directly at any stage and help to put in place any measures that can help to facilitate the positive experience of birth that is so important to them.

Adding value

Better outcomes – Changes within services as a result of these clinics include:

• Partners are now able to stay on the ward when the woman has gone into labour on the ward overnight.
• Women who had previously been deemed unsuitable to give birth at the midwife-led birth centre are now able to use these facilities. The clinic ensures that a robust birth plan is in place which is communicated to all staff involved.

Complaints about maternity care have dropped significantly. From April 2016-March 2017 there were 18 but from April 2017 to November 2017 only 3. This demonstrates the positive impact of offering face-to-face meetings to resolve issues or concerns in a more satisfying way and ensuring that women are being placed at the centre of their care. Women who chose not to make a complaint are given the option of sharing their concerns face-to-face with one of the Matrons. Following this, it is explained that they still have the option of going through the formal complaints process if they would like to. However, to date none of them have chosen to proceed as they are happier with the outcome of having been listened to and had their feelings validated.

Better experience – 100% of Friends and Family Test’s (FFT’s) completed would recommend the service to their friends and families. Feedback is also included in ‘Maternity Voices’ as part of the local Maternity Voices Partnerships.  It is important service users are aware that this clinic is available with no time limit and that we act on any concerns that have been raised.

Reflections on case studies are discussed at team meetings and staff development days, which enhances practice.

Women and partners are often followed up with feedback and the Matrons have significant numbers of cards and texts saying what a difference the consultation had made.

Staff feel more empowered to be able to support women, knowing that plans have been put in place at a senior level. They have access to clear plans and greater understanding of the individual user needs and awareness of the impact this has on their wellbeing.

Previously, staff had concerns when women chose to go against medical advice. Recognising that supporting and involving women is key to understanding their experiences and keeping them at the centre of care. Having an individualised plan in place ensures that the care is as safe as it can be and that the appropriate members of the multi-disciplinary team are involved.

Better uses of resources – Women are no longer seen on an ad hoc basis enabling Matrons to identify themes and feedback to teams and individual midwives. It has also enabled us to look at services provided and make changes based on women’s experiences. Complaint reduction has freed up time for the Midwifery teams including the Matrons so they can focus on patient care.

Challenges and lessons learnt for implementation

Sharing information with the multi-disciplinary team has helped break down barriers and reduce anxiety. All Staff feel it has been beneficial for women in their care to have an opportunity to discuss concerns and have questions answered face-to-face rather than a written response.

The benefit for women and their families is huge for them; having access to a service that supports closure and shared understanding following a poor experience whether from the birth or postnatally. Providing reassurance that their concerns are addressed and there is organisational learning from their feedback.

Women are at the centre of midwifery care. Always listening to what women want/need to ensure a positive birth experience improves the quality of care delivery.

Passionate patient engagement is essential. Staff working within the service must value patient feedback and be driven to use it to develop services not just resolve a complaint.

It’s important to not be afraid of saying ‘sorry’, this simple word can validate someone’s feeling and has made a huge difference.

Offering a self-referring option for women without time restraints in place helped.

Share the learning from the clinics to practitioners working within services.

Enabling parents to feel positive about their birth reduces anxieties, increase confidence and reduces mental health problems following the birth.

Following on from the clinics the Matrons have developed a template for a ‘Birth against advice’ plan which clearly states the women’s wishes and who has been involved in her care planning for the birth. This plan once complete is circulated to the multidisciplinary team.

By involving midwives it will meet several requirements of the A-EQUIP clinical supervision model particularly ‘undertaking quality improvement in collaboration with women’.

Find out more

For more information contact:

• Anne Richley, Matron, Anne.richley@ngh.nhs.uk