Focus on outcomes for mothers and babies
The final blog in a series of four that looks at how to improve clinical quality in maternity services - so mothers and their babies enjoy great care and staff enjoy their work. Here, I look at why outcomes measures are important. And then consider three steps that maternity services can take to use outcomes measures effectively when improving quality effectively.
Value in healthcare
Value in healthcare is about achieving ‘the best outcomes for patients at the lowest cost’ (Porter & Lee 2013). This common goal unites all those involved in healthcare (Porter 2010).
Why outcomes?
Outcomes – what mothers and their babies need – are key to the assessment of value in maternity services. Often maternity services indicators measure process (e.g., the number of clinical staff trained in smoking cessation) or activity (say, the number of smokers referred at booking). Whilst these measures may be important in local quality improvement projects looking to tackle specific issues, Porter argues that our primary focus needs to be on outcomes (e.g., the stillbirth rate).
The three steps
Porter says we need to take three steps if we are to improve outcomes and reduce costs responsibly:
measure outcomes
report outcomes
compare outcomes
Let’s look at each of these three steps as they apply to the Every Birth a Safe Birth model for maternity clinical networks.
Step 1: measure outcomes
When measuring outcomes consider:
both mother and baby across all phases of maternity care
all dimensions of quality
near and longer term outcomes
Maternity services are unique in healthcare in that the mother’s and her baby’s health are deeply intertwined during all phases of care: antenatally, during the intrapartum period and postnatally. What affects one invariably affects the other. Therefore, outcomes indicators should reflect each phase of care for mother and baby.
Cover all dimensions of quality. Six dimensions of clinical quality are widely recognised (Institute of Medicine 2001). For some dimensions, collating a set of indicators is straightforward. Safety, for example, might include infection rates or intrapartum stillbirth. But what about equity? Is this systematically reflected in local outcomes measures?
Measures should encompass near and longer-term health: that is, a sufficient time period to encompass the ultimate results of care (Porter 2010). In the UK, heart disease is the leading cause of maternal death during or up to six weeks after the end of pregnancy; mental health problems are a leading cause of death in pregnancy and the 12 months after birth (MBRRACE-UK 2016). Therefore, measuring maternal mortality during both the near term (up to six weeks after the end of pregnancy) and longer term (up to 12 months after birth) is important in order to address the direct causes of maternal death.
Step 2: report outcomes
To enable change, report outcomes:
using current data
at unit level
visually
Current data lets teams see how effective their changes to improve quality have been. If an idea has not been effective, it can be stopped quickly - minimising the waste of resources. If an idea is effective, it can be scaled up – increasing the impact of the change.
Unit level data can flag up improvements or problems at an early stage: changes in outcomes at one unit can be lost when data is aggregated for the organisation as a whole.
It easier to visualise trends from a graph than a colour-coded data table; graphs show, at a glance, both the direction of the trend and the rate of change.
An example graph is shown in the poster presentation I gave to the Royal College of Obstetricians & Gynaecologists Women's Health Patient Safety Day in 2015.
Step 3: compare outcomes
To improve quality, outcomes must be reviewed and action taken. Organisations that improve quality in the medium to long term tend to:
collaborate - organisations compare care, share ideas and provide challenge
hold regular multidisciplinary learning sessions, where local teams review outcomes at unit level and design and implement improvement initiatives
train teams in quality improvement tools
appoint regional and local clinical leaders
ensure programme delivery support and protected time for leaders
This type of collaborative approach is credited with: a 10% reduction in stillbirth rate and a 11.5% reduction in neonatal death rate in one year in Scotland (The Health Foundation 2015); and 293 fewer deaths than the 868 expected by six cardiac units in Boston, USA (Malenka & O’Connor 1998).
The Every Birth a Safe Birth model for maternity clinical networks supports teams to continuously improve the quality of maternity services through a focus on outcomes for mother and baby and the use of a tried and tested collaborative approach.
