Aquality improvement project was initiated with the aim of increasing home birth within a London NHS trust. In 2016, the ‘Better Births’ report (NHS, 2016) was published. As an early adopter for the ‘Better Births Maternity Transformation Programme’ (NHS, 2019), the unit had targets to increase it's continuity of carer and to support more out-of-hospital births. Meeting both targets aims to:
As part of the project, the following were undertaken:
The overall (author's emphasis) aim of the project is to increase the home birth rate for the trust by 100%. The home birth rate for the trust at the start of the project sat at just under 1% (47 home births per annum) and the overall impact of this is still to be determined as it requires a full 12-month audit of the figures. This report considers the implementation of a new home birth kit for the community midwives.
Quality improvement
Quality improvement is a continuous cycle and is the systematic process of ensuring and sustaining high quality healthcare that is safe, effective, patient-centred, timely, efficient and equitable (Health Foundation, 2013; Jabbal, 2017). It usually involves the use of varied quality improvement tools and methodologies that are focused on improving processes, systems and clinical practice (Health Foundation, 2013).
In recent times, the NHS has worked to embed quality improvement into its culture (NHS Improvement, 2017a) and has considered how effective leadership supports and promotes quality improvement within the NHS (2017b). Jabbal (2017) is clear. However, for effective quality improvement to take place, leaders need to recognise that staff require time away from their ‘daily roles’ to participate in quality improvement projects. With the new role of the professional midwifery advocate (PMA) that is underpinned by the advocating for education and quality improvement (A-EQUIP) model (NHS England, 2017a), there is the potential for PMAs to support midwives in identifying their own ‘personal actions’ for quality improvement which could contribute to sustaining high quality care.
In January 2019, a quality improvement project to increase the home birth rate for women under the care of a London NHS trust was developed. As an ‘early adopter’ for ‘Better Births’, the trust has been targeted with:
A SWOT analysis (Figure 1) was undertaken at the start of the project to review the current home birth rate and continuity of carer provision, and, from this, a driver diagram (Figure 2) was created to map out how the aim of increasing the home birth rate could be met. A driver diagram is a quality improvement tool that clearly visualises the often multiple aspects – or ‘drivers’ – of an improvement project that enables the team to work collaboratively on each driver that contributes to the overall aim of the project (Institute for Health Care Improvement, 2017). Put simply, it is a ‘visual strategy for tackling a complex problem’ (East London NHS Trust, 2019).
The quality improvement tool called PDSA (Figure 3) was then used to systematically approach each of the individual ideas for the driver diagram that would enable the secondary and then the primary drivers to be met. This tool was chosen as it works well where individual changes are tested in small cycles and starts with the three key questions that will drive the change (Health Foundation, 2013):
Change in the NHS requires ‘good leadership’ and the capacity to bring people ‘alongside’ (Capito, 2019). Leadership in maternity is essential, not just for developing quality improvement initiatives that enhance provision for mothers and babies, but also for developing the midwives' capacity for providing safe and effective women-centred care (Royal College of Midwives, 2014; Faculty of Medical Leadership and Management [FMLM], 2015). While Byrom and Kay (2011) consider that all midwives ‘lead’, leadership within midwifery is variable and not always of the highest quality (Warwick, 2015; Bannon et al, 2017).
The NHS ‘Culture and Leadership’ programme highlights the need for NHS providers to develop cultures that ‘enable and sustain continuous improvement’(NHS Improvement, 2017b). The programme describes the traits of ‘inclusive leadership’ and explores the principles of ‘compassionate leadership’—models that are more likely to enable staff to bring ‘wisdom, compassion, intelligence, commitment, courage and emotional intelligence to their work’ (NHS Improvement, 2017b).
Compassionate leadership is particularly apt within the healthcare setting, where compassion is one of the core values of the NHS (NHS Constitution, 2015). Compassionate leadership consists of four ‘branches’ that aim to include the stakeholder (West et al, 2017; NHS Improvement, 2017b). These branches are:
The four branches of compassionate leadership (Figure 4), when applied to quality improvement, can help ensure that the improvement is not a ‘top-down’ approach but rather a collaborative approach with all stakeholders involved (NHS England, 2014; Jabbal, 2017). This, in turn, may lead to a more sustainable and satisfactory implementation of the change proposed (NHS Institute for Innovation and Improvement, 2010). The compassionate leadership approach was used within the project.
Leadership should also include clear aims and a clear purpose or ‘vision’ (FMLM, 2015). ‘Goal setting’ results in ‘markedly high performance’ and the evidence supports that if goals set are ‘specific and manageable’, they are more likely to be achieved (NHS, 2017b). The home birth rate for this NHS trust was approximately 47 births per annum (1%); increasing this to approximately 100 births per annum (2%) is in line with the national average (Office for National Statistics [ONS], 2019) and, over the course of a 12-month period, is both specific and manageable.
The project
With the targets of implementing the ‘Better Births’ (2019) aims, an initial consultation from senior management within the trust was put forward for the reconfiguration of the existing ‘traditional’ community teams. Case loading was offered as a potential change in line with the ‘Better Births’ agenda and midwives were invited to indicate their preferred way of working. As a result of the consultation, a midwife with a keen interest in promoting and facilitating home birth and home assessment put forward a proposal to develop a dedicated home birth team that would:
The proposal was accepted by senior management and a SWOT analysis (Figure 3) of the current home birth provision undertaken. Home birth has been well-evidenced as a safe choice for place of birth (Hollowell et al, 2011) with no difference in outcomes for women having their second and subsequent babies at home. Despite the National Institute for Health and Care Excellence (2017) recommendation that home birth be offered to women in pregnancy, evidence still indicates that women are not always offered information around their choices for place of birth (NHS, 2016; Coxon et al, 2017). An audit of the current home birth rate within the trust was carried out which confirmed that the home birth rate was approximately 1%. With a home birth rate of half the national average (ONS, 2017), it was considered that this might be a reflection within the trust that midwives were not always offering women the choice to give birth at home; an online survey completed by 50% of the community midwives revealed that 50% of respondents ‘do not always offer home birth’ as a birthing option (Figure 5).
In order to move forward with the overall aim of increasing the home birth rate, the four branches of the compassionate leadership model were utilised. With any change, it is important that the stakeholders are identified (NHS Institute for Innovation and Improvement, 2009). Stakeholders are those whom will be directly impacted by the proposed changes and the community midwives were identified as the primary stakeholders who deliver the home birth service.
PDSA
Using the quality improvement PDSA tool kit, the following questions for the home birth kits were addressed:
Plan
The original home birth equipment provision was viewed as ‘messy and disorganised’ (personal communication, 2018). Comprising a rucksack and an additional ‘stack-and-roll trolley’, the ‘first on-call’ midwife would need to carry these two items, her own basic equipment, Entonox and tubing, suction, and resuscitation equipment when attending to a woman at home-a total of five separate and bulky items. The equipment checklists indicated that equipment reviews were infrequent. Emergency drugs were often out of date and specific items were difficult to locate or missing from the kit altogether.
Inviting stakeholders to contribute towards change results in increased likelihood that the change will be welcomed and implemented (NHS England, 2014; Jabbal, 2017). A home birth forum invitation was sent to all community midwives to provide feedback on the current equipment and gather ideas on how to move forward. The meeting was attended by around nine midwives (30%) of the community workforce who attend home birth. Funding within the NHS remains a consistent challenge (NHS England, 2017b); a small budget of £100 was made available to invest in some new equipment. A degree of creativity and initiative were required to update two home birth kits with the allocated budget and various options were considered and reviewed, namely:
The rucksacks were considered difficult to keep organised and well-stocked; the Baby Lifeline bags were still on trial and not available to purchase, and other NHS trusts that reviewed the bags used different methods with no consistency. These findings were reflected in the Baby Lifeline (2019) stakeholder survey.
Following the feedback that the rucksacks were disorganised, a cheap and easily accessible option was to use ‘tool kit trolleys' that tradesmen use. These trolleys could hold larger pieces of equipment, allowed ‘consumable items' to be well-organised, and, as they were on wheels, this meant midwives did not have to lift and carry additional equipment. To further reduce the amount of equipment midwives had to carry to each birth, home birth packs were created and arranged to be delivered to the women at their 36-week home birth booking; midwives were invited to contribute ideas on what went into these packs.
Do
The new home birth kits were created and a second home birth forum was arranged to present the new trolleys. The consultant midwife for normality was invited to attend. New unit guidance (NHS Trust, 2018) had updated the drug regime for postpartum haemorrhage to include 1 gm of tranexamic acid as the second line of intervention for managing a postpartum haemorrhage and the consultant midwife was able to give an overview of the latest evidence and discuss the new local policy. Midwives were voicing anxiety and concern about administering tranexamic acid which is delivered slowly via an intravenous (IV) cannula; ‘emergencies in the community’ workshops were developed as a result of these concerns (see ‘Study’ below).
The new home birth equipment was left in the community office two weeks prior to launching the new trolleys and midwives were invited to explore the equipment and provide immediate feedback. A few amendments were made to the trolleys. These included:
The new home birth kits were officially put into practice on the 1 February 2019.
Study
In keeping with compassionate leadership, ‘emergencies in the community’ workshops were developed as a result of midwives voicing anxiety and concern about administering tranexamic acid via an IV cannula. These workshops used the new home birth equipment and provided an opportunity to practice cannulation skills, and to share best practice ideas in a safe environment, utilising different teaching styles. Evaluations of the study day were analysed.
The previous home birth equipment often remained unchecked, with items sometimes missing from the bags. New guidance from the community matron had been put in place via the community team leaders requesting that the first on-call midwife should carry out a full check of the equipment every Monday. Over a period of two months, the home birth checklists were audited to confirm if the kits were being checked weekly. Six months after the implementation of the new home birth equipment, an online survey to collect midwives' views was distributed.
Act
The home birth kit included the new tranexamic acid; workshops were developed to address midwives concerns around cannulation skills. Four workshops were planned and two were cancelled due to low attendance. Evaluations from the two workshops that ran indicated that 70% of attendees ‘felt more confident’ in managing a postpartum haemorrhage.
Audits of the home birth checklists confirmed that weekly checks were not occurring. Feedback from midwives suggested that, due to staffing and clinical activity throughout the week, Fridays would be a more appropriate day to check equipment.
A 50% response rate to the Survey Monkey was achieved. There were 80% of midwives who reported that the new equipment was ‘better’ or ‘much better’ than the old equipment (Figure 6). Midwives reported that the provided thermometers were inaccurate with low temperatures being recorded in babies resulting in some unnecessary hospital transfers.
As quality improvement is a systematic cycle, the next phase for the PDSA has been set:
Conclusion
The ‘Better Births Maternity Transformation’ programme (NHS, 2016) is a committed overhaul of the current NHS maternity provision. The desired outcomes of the project has significant bearings for all the stakeholders involved. The overall aim of this project as part of the ‘Better Births’ agenda is to increase the home birth rate by 100%. Reaching that aim requires a breakdown of the individual contributors that enable it to be met. The home birth kit was identified as a barrier to midwives offering women the choice to birth at home and the project aim was to deliver a new home birth kit that would increase midwives' confidence in attending home births.
Through the use of quality improvement tools and utilising compassionate leadership, the project aim was met: 75% of midwives reported they felt increased confidence in attending home birth with the new equipment offering (Figure 7). The report concludes that through the systematic use of quality improvement tools, employing a visible leadership model and by setting clear aims, the desired change outcome is more likely to occur.
