In 2015 the trust was under special measures and the maternity unit was rated as ‘inadequate’. This had a negative impact on recruitment and retention. The maternity department had a high midwifery staffing vacancy rate (25% in 2016) and was heavily reliant on agency staff. There was a risk that this would impact on the quality of patient care. We developed a recruitment and retention plan in collaboration including a preceptorship programme, new ways of working, and career progression opportunities including new roles. The plan draws on best practice from the National Maternity Review 2016 and the Safer Childbirth report.
We have turned around an ‘inadequate’ maternity unit to achieve a ‘good’ rating in the 2016 CQC inspection.
•Team building: £5,000
•Additional posts: £100,000
Our use of agency staff has dramatically decreased. Our high costs were attracting negative media coverage and affecting our reputation. We have cut agency costs from £100,000 per month in 2016 to £30,000 as of June 2017. We expect these costs to continue to drop with the aim of reaching zero. We have more than halved the number of agency staff (from 14% in 2016 to 6% currently). This has a direct impact on quality of care and safety of patients.
For example, a ‘never event’ in 2016 was directly attributable to poor practice by an agency nurse who failed to follow correct procedures. Since we increased the number of substantive staff and invested in a robust learning process, we have had no further never events (no never events from September 2016-June 2017). We have reduced waiting time for appointments in the ante natal clinic from an average 60 minutes to 30 minutes and we are continuing to reduce it further. We held team building events to create a sense of ‘one team’ and to tackle historical cultural and behavioural issues.
All staff were included: domestic (cleaners), nurses, doctors, midwives, maternity support workers, managers, consultants, executive directors, administrative staff, human resources, and students. We developed a collective vision for the unit, set out our values and our five-year strategy to develop the service. We also developed a charter of behaviour to set out how we treat each other and patients. Patients were involved through our Maternity Liaison Service User Committee which contributed to the wording of our vision and values.
We created new teams:
•Phoenix team provides continuity of carer for low risk women
•Lavender team looks after vulnerable women, especially focusing on mental health issues.
To make best use of midwives’ skills and time, we introduced a new role to take on non-midwife essential tasks. The Associate Nurses/Maternity Support Worker role supports the midwifery team. Maternity Health Care Assistants (HCAs) are encouraged to apply to improve retention. A new rotational post of Support Risk Midwife gives clinical midwives more insight into risk and governance, and is intended to have a long term effect on clinical practice. Flattening the structure and creating clear career progression routes has attracted more staff to join the unit.
The maternity unit was the highest in the UK for use of agency midwives (14%) in 2016 which affected quality, safety and costs. We have reduced agency staff to only 6% in June 2017. Agency spend has reduced from over £2million in 2015/16 to £912,000 in 2016/17.Since we increased the number of substantive staff, we have had no further never events. We have improved our risk management through: strengthening the unit structure, thorough investigation of incidents, wide dissemination of learning and sustained practice improvement. We have reduced waiting time for appointments in the ante natal clinic from an average 60 minutes to 30 minutes.
The maternity unit’s work on changing culture and improving staff engagement has been replicated in the trust’s emergency and children’s departments.We have shared our work with our Local Maternity Systems (LMS) workstream of the sustainability and transformation partnership. As a result, other hospitals are actively considering adopting the Lavender team model. We also shared our learning on risk management and governance and we are now peer reviewing each other’s Clinical Incident Reports. This is groundbreaking – we are the only LMS in East of England implementing this. We presented our improvement journey nationally at the Maternity Midwifery and Baby event.