Maternity Transformation Newsletter May 2021

Welcome to your new, monthly, Maternity Transformation Programme (MTP) newsletter.

MATERNITY TRANSFORMATION PROGRAMME NEWSLETTER MAY 2021

This newsletter will keep you up-to-date on information from the MTP, which aims to achieve sustainable improvements within maternity services, whilst focusing on the implementation and embedding of all 27 Local Actions for Learning and 7 Immediate and Essential Actions (consisting of 25 sub-items), outlined in the first report from the Independent Maternity Review, chaired by Donna Ockenden.

Each of these actions have been assigned to one of five MTP workstreams, with the exception of a small number which require corporate attention.

The Maternity Improvement Plan, consisting of Saving Babies Lives Care Bundle 2 and the CNST Maternity Incentive Scheme, is now incorporated with the rest of the MTP in the new, ‘Workstream 6’. More information will follow on Workstream 6 in next month’s MTP newsletter.

Project Aims and Outcomes 1. Implement and embed all 52 Ockenden Report actions by October 2021 2. Evidenced delivery of Year 3 CNST 10 safety action by July 2021 as per the revised NHS-R submission deadline 3. Evidenced delivery of all RCOG actions to be completed autumn 2021 4. Evidenced delivery of CQC action plans by autumn 2021 5. Development and delivery of communications and engagement plan for patients, families and key stakeholders by autumn 2021 If you have any questions, or would like to be involved with the work of the MTP, please email sath.maternitytransformation@nhs.net

WORKSTREAMS Workstream 1: Clinical Quality & Choice Achievements Vision - “To deliver a high-quality, safe, effective and personalised service to ensure women and babies receive the best care to meet their wishes and needs”

Workstream 2: People and Culture

Vision - “An inclusive culture where staff are valued, listened to and supported to deliver patient centred care”

Workstream 3: Governance and Risk

Workstream 4: Partnership, Learning and Research

Workstream 5: Communications and Engagement

Vision - “To deliver a safe maternity service that is underpinned by a first-class clinical governance process, to drive and improve the delivery of highquality personcentred care”

Vision - “A forwardthinking, Gold Standard Training Scheme for Maternity services at SaTH underpinned by robust research and highquality partnerships”

Vision - “To Regain the Trust of all stakeholders in Maternity Care provided by SaTH

Project Lead

Project Lead

Project Lead

Project Lead

Project Lead

Guy Calcott

Janine McDonnell

Nicola Wenlock

Will Parry-Smith

Mei-See Hon

Diana Martin 2

Maternity Transformation Programme newsletter

DONNA OCKENDEN – KEY MESSAGES First Ockenden Report published on 10.12.21, following 250/1862 cases. The report revealed Emerging Findings and Recommendations from the Independent Review of Maternity Services at SaTH. • 27 Local Actions for Learning (LAFLs) specific to the Trust • 7 Immediate and Essential Actions themes (IEAs) for all NHS providers of maternity care with 25 related actions: • IEA 1: Enhanced safety • IEA 2: Listening to women and families • IEA 3: Staff training and working together

• IEA 4: Managing complex pregnancies • IEA 5: Risk assessment throughout pregnancies • IEA 6: Monitoring fetal wellbeing

Delivery Status Total number of Actions

Not yet delivered

Delivered, Not Yet Evidenced

Evidenced and Assured

LAFL

27

15

12

0

IEA

25

17

8

0

Total

52

32

20

0

Progress Status Total number of recommendations

Not Started

On Track

LAFL

27

0

25

0

2

0

IEA

25

3

20

0

2

0

Total

52

3

45

0

4

0

At Risk (see Off Track (see exception report) exception report)

Completed

The next Ockenden Report Assurance Committee (ORAC) meeting will take place from 09:00-11:30 on Thursday 27 May. A link to view the meeting will be available 48 hours before the meeting takes place and can be found by clicking here

Maternity Transformation Programme newsletter

3

WORKSTREAM 1: CLINICAL QUALITY & CHOICE ACHIEVEMENTS TO DATE (APR-21) Updates from 2020: • • • • •

WORKSTREAM 1

New updates: • • • • • • • • •

4

•

On Track (Delivery): 33.3%

Complete: 3.8%

Not started: 30.8%

Off Track: 2.6%

On Track (embedding): 28.2%

At Risk: 1.3%

Two continuity of care teams went live in September 2020 New booking guide for midwives/ forms for mothers designed to support informed choice of care pathways Introduction of monthly MDT personalised care plan meeting to ensure support to mother’s chosen plan is put in place Postpartum haemorrhage (PPH) review carried out and recommendations prepared Introduction of more physio care and information for postnatal care of mother and baby

Critical care training plan scoped and presented to WS4 lead (Feb-21) Audit of continued risk assessments underway in partnership with SBL project midwife (Feb-21) New Personal Care and Support Plan published and adopted by Dudley Hospital as good practice (Feb-21) New postnatal information video acquired from Gloucestershire NHS Trust, adapted and rolled out (Feb-21) Continuous glucose monitoring enhanced process implemented (Mar-21) Band 6 physiotherapist recruited for the pelvic health team (Mar-21) Successful bid for Maternity Mental Health Service (MMHS) (Tokophobia, loss & birth trauma) (Mar-21) Ockenden actions 4.55, 4.62 and 4.63 agreed as delivered, not yet evidenced (Mar-21) Implementation of continuous glucose monitoring to meet the requirements of NHS England Glucose Monitoring for Women with Type 1 Diabetes (Apr-21) Launch of ‘business cards’ to be issued to mothers on discharge, with direct QR links to contemporaneous information (Apr-21)

Maternity Transformation Programme newsletter

WORKSTREAM 2: PEOPLE & CULTURE ACHIEVEMENTS TO DATE (APR-21) Updates from 2020: • • • •

Project steering group established for MSW role (Sep-20) Booklet compiled on support available for staff within SaTH, printed and each staff member has received their own hard copy (Nov-21) Survey on staff feelings/culture issued (Nov-21) Listening Clinics established for month of December 2020 – staff 8am-8pm, 7 days per week (Dec-21)

New updates: • • • • • • • • • • • • • • •

“Making a difference” Platform launched (Jan-21) Training providers for apprenticeship programme evaluated (Jan-21) Project Midwife recruited to undertake competency framework preparation & to assist with MSW assessment (Jan-21) Action learning development course for Division designed in partnership with MPFT with 20 staff involved as key influencers or support advocates (Oct 20 – Jan 21) Actions Learning Set - Key influencers programme rolled out (Feb-21) Medical leadership and Divisional Senior team undertaking leadership courses Partnership in place with Sherwood Forest Trust to share and learn from (Feb21) Dominant, Inspiring, Supportive & Cautious (DISC) Analysis for all Band 7’s completed (Mar-21) Competency framework and assessment methodology scoped for MSW roles in line with HEE requirements (Mar-21) Number of MSW’s required established in line with workforce planning requirements and BirthratePlus (Mar-21) “Safe space” listening services carried out throughout maternity and neonatal services (Apr-21) Observation plans for ANNPs and consultants at other NICUs agreed (LAFL 4.100) (Apr-21) Roll out of B7 “ root programme” commenced following TNA and 1:1s (Apr-21) MSW B3 project underway with project plan and competency framework now in place (Apr-21) Key influencer programme commenced in partnership with midlands partnership foundation Trust (MPFT) with 20 staff involved across the division doing a 12 month development programme looking at a range of topics including civility saves lives and trauma informed approach

Maternity Transformation Programme newsletter

WORKSTREAM 2

On Track (Delivery): 59.2%

Not started: 30.6%

On Track (embedding): 6.1%

Off Track: 4.1%

5

WORKSTREAM 3: GOVERNANCE & RISK ACHIEVEMENTS TO DATE (APR-21) Updates from 2020: • Band 8 “quality improvement midwife” appointed specifically to support this and the other MTP workstreams • Band 6 project midwife allocated • Escalation process reviewed and strengthened • Weekly ad-hoc MDT SIM training in place on delivery suite • Weekly MDT incident review meeting

New updates:

WORKSTREAM 3

6

On Track (Delivery): 59.2%

Not started: 30.6%

On Track (embedding): 6.1%

Off Track: 4.1%

• Quality and Improvement Matron in post (Feb-21) • Audit requirements of Ockenden Report Plan outlined and initial action plan agreed with care group governance lead (Feb-21) • MIP imported to project management tool (Feb-21) • Formal project support in place for Maternity Safety Champions working group (Feb-21) • Medical and nursing notes combined in Neonatal Unit, per Ockenden requirement 4.97 (Feb-21) • Liaison with clinical audit team to support the evidencing and assurance of the Ockenden deliverables (Apr-21) • Liaison with the Kaizen Promotion Office underway to apply Quality Improvement methodology to support improvements in Anaesthetics in line with the RCoA Guidelines for the Provision of Anaesthetic Services (Apr-21) • Snap audit to confirm that continuous electronic fetal monitoring during Oxytocin infusion is meeting high level of compliance other than the use of the sticker system completed, to support the delivery of Ockenden action 4.64 (Apr-21) • Ockenden action 4.64 and 4.97 agreed as ‘Delivered, Not Yet Evidenced’ (Apr-21)

Maternity Transformation Programme newsletter

WORKSTREAM 4: PARTNERSHIP, LEARNING & RESEARCH ACHIEVEMENTS TO DATE (APR-21 Updates from 2020: • •

Benchmarking of current state of training for maternity within the Trust commenced Progress with qualitative research: • Partnership formalised and commissioned with Birmingham City University (BCU) • Expressions of interest for family interviews with MVP: 70 emails/SMS received expressing interest to take part in study • Expressions of interest for staff interviews: 30 total expressions of interest to take part in study and 15 interviewed

New updates: • • • • • • •

WORKSTREAM 4

Interim research report received from Birmingham City University (BCU) for staff and families regarding maternity service improvement (Feb-21) Partnership with Birmingham University sourced to aid with the quantitative research to improve maternity services (Feb-21) Agreement with Education Team to use Maternity as a pilot division for the newly sourced LMS rollout (Feb-21) Benchmarking of training completed (Mar-21) Gap analysis completed for training completed (Mar-21) Training matrix completed detailing full standard requirements for training (Mar-21) Partnership with University of Birmingham agreed to conduct quantitative research (formalisation underway) (Apr-21)

Maternity Transformation Programme newsletter

Not started: 61.5%

At risk: 7.7%

On track (delivery): 7.7%

Complete: 23.1%

7

WORKSTREAM 5: COMMUNICATIONS & ENGAGEMENT ACHIEVEMENTS TO DATE (APR-21) Updates from 2020: • Communications Specialist recruited specifically for the MTP • Stakeholder mapping begun to ensure all allocated and involved parties are appropriately engaged and communicated with • MVP links established

New updates:

WORKSTREAM 5

On Track (Delivery): 7.7%

• Monthly MVP meetings conducted to create a safe space for open and honest conversations to aid with Maternity improvement (Since Jan-21) • Production of posters / leaflets; including midwifery staff Listening Sessions, flu jabs for pregnant women, ‘if you are pregnant, we want you to know’ information. These posters now appear on our website and (where relevant) on Trust social media pages (Feb-21) • Agency sourced for maternity website redesign/social media development (Mar-21) • COVID-19 Vaccination during pregnancy video completed (Apr-21) • Two MTP Noticeboards designed and hung up in W&C (Apr-21) • Midwifery-led Unit (MLU) Virtual 360 Video Tour completed and launched (Apr-21)

Complete: 15.4%

Not started: 76.9%

8

Maternity Transformation Programme newsletter

MATERNITY TRANSFORMATION PROGRAMME (MTP) • The MTP was launched on 13.08.20 • Funding secured for transformation work • PMO team was recruited in September-November 2020 The aim of MTP is to ensure the correct implementation of the Ockenden actions and recommendations, plus to make maternity services in SaTH become amongst the safest and most trusted in the country. In order to deliver said actions, five workstreams have been designed, each with a vision and workstream leads, sponsors and project managers.

1

Clinical quality and choice

Executive Sponsor: Hayley Flavell (Director of Nursing) Workstream Lead: Mei-See Hon (Clinical Director Obstetrics) and Guy Calcott (Consultant Obstetrician) Project Manager: Tom Baker

2

People and Culture

Executive Sponsor: Rhia Boyode (Director of Workforce) Workstream Lead: Janine McDonnell (Care Group Director) Project Manager: Cristina Knill

3

Governance and risk

Executive Sponsor: Anna Milanec Workstream Lead: Nicola Wenlock (Director of Midwifery) Project Manager: Tom Baker

4

Partnership, learning and research

Executive Sponsor: Arne Rose Workstream Lead: Will Parry Smith (Clinical Lead for Research and Innovation) Project Manager: Cristina Knill

5

Communication and engagement

Executive Sponsor: Anna Milanec Workstream Lead: Mei-See Hon Project Manager: Tom Baker & Cristina Knill

Maternity Transformation Programme newsletter

9

MTP PROJECT MANAGEMENT TEAM Tom Baker (Senior project manager) ‘I joined the Trust in November 2020 as Senior Project Manager for the Maternity Transformation Programme.

Prior to this I spend 5 years as a project manager in the financial sector, and before that, 7 years as an infantry officer in the British Army. I was born at RSH in 1985 and my daughter was born at PRH in 2017, so I feel a close bond to the Trust’.

Cristina Knill (Assistant project manager) ‘I joined SaTH in November 2020 as Assistant Project Manager for the MTP. In 2017 I graduated in BSc Biomedical Engineering from Barcelona University and worked at Hospital Clinic Barcelona, employing Lean principles to optimise the medical supply chain using Smart Kanban tools. In 2018 I moved to the UK and worked as a project manager for a pharmaceutical company, developing solutions for Cellular Pathology Labs.

I have a real passion for process engineering and delivering robust and efficient solutions to optimise and improve services’.

Cecile Le Goff (Project Admin) ‘I joined the Maternity Transformation project Team in November 2020 as Project Administrator. Prior to that, I spent 8 years in the private sector working for the Learning and Development function, supporting organisations in achieving their goals through the development of their workforce. I worked for companies within the IT and Waste Management industries, both in the UK and in France where I am from.’

10

Maternity Transformation Programme newsletter