Service Planning Improvement Reflection

through focus groups between midwives, paediatricians and obstetricians and achieving level 2 on the ICF CW3. I am also working at level 2 on the ICF CW4 as I participate in collective decision making but not autonomously. I do feel that I achieve level 3 at times but this is not consistent and usually due to lack of confidence or lack of knowledge of the wider community of practice.

Connecting our service is to understand how health and social care fits together and how people, teams or organisations interconnect and interact. During placement I engaged with a lady with complex mental health issues. To ensure continuity of care I worked with her to devise an individualised birth plan involving the mental health specialist midwife, antenatal and postnatal managers, theatre staff and her GP. I also attended hospital with her for the birth which is outside the remit of a community midwife, however, she needed the support of one person who could coordinate an integrated plan. On reflection it was good to see how working in partnership with others can benefit service users with individual needs. While guidelines for care may be in place it was important to negotiate with others for the benefit of service user’s health and well-being (NHS England, 2013; NMC Nursing and Midwifery Council, 2015). I have assessed myself at level 3 on the ICF CW1. A difficulty that needed to be addressed was the ability to connect right people at same time. On occasions this was less effective, for example, GP contact was by telephone and the lady could not attend all meetings. If we are discussing issues around the care of a person how can it be truly person centred if they are not in attendance and decisions are made for them not with them.

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Influencing for results is about the ability to have a positive impact on others while being sensitive to their needs. During placement I was completing an initial risk assessment on a lady and it transpired that she had alcohol problems. Raising the sensitive topic of alcohol consumption can be uncomfortable (O’Malley 2010, Winstone & Verity 2015) but as I have recently worked with the specialist substance abuse midwife I was confident talking with the lady, obtaining a true picture of her usage and offering sound information and advice. My mentor was observing which made me self-conscious but I also felt supported knowing she would step in if she felt it was necessary. I was able to demonstrate awareness of care outcomes, relating this to the evidence base and I was able to offer immediate advice suited to her individual needs until she could see the specialist for a full intervention and care plan. The feedback from my mentor regarding my interpersonal skill was positive and has given me confidence to tackle sensitive issues again in future.  I have assessed myself at level 3 on the ICF CW2.

NHS Improving Quality (Bevan & Fairman, 2014) takes a radical approach to management and change, with the aim of overhauling traditional hierarchal styles and instead promoting a shared purpose with diversity of experience and creating influence through networks.  I am going to underpin these principles through my SI.

Initially, I would identify and engage with a small number of key individuals, both at a senior and operational level, to sound out my idea and to ensure support moving forward (Lúanaigh, Carlson, & Davis, 2005). I would approach those I have seen previously engage positively with staff and those that listen to ideas and that show passion in their own work attitude. I would use a plan-do-study-act cycle (PDSA), see appendix 3. The strength of this method is that change can be introduced quickly and efficiently on a small scale with early identification and correction of problems prior to wide scale implementation (Kerridge, 2012).

Within my Trust we currently provide Postnatal Care Plan’s for Mother and Baby which incorporates information and advice. However, having spoken to women in the community many do not read the information (30 and 31 pages long respectively) as the initial period when they return home is concentrated on getting to know their newborn and recovering from childbirth. We also provide a lot of information in the hospital verbally with regards to signs and symptoms of illness, exercise, contraception, registering the birth etc. and some women have voiced to me that it is “information overload”. The issue is further exasperated by the fact that we return the plan’s to the hospital when patients are discharged from the community midwife (around day 10) so there is an expectation that information is read and understood in a short space of time.

The SI is to add a sticker to the discharge envelope for postnatal women to provide information about the signs and symptoms of sepsis so that women and their families can better understand when and where to seek help (see appendix 4). This is a visual for the women, is easily accessible and stays with the women after discharge in the community.

The rationale for my SI is that for several years sepsis has been highlighted as a public health concern with the first international guidelines for management issued in 2004 (Dellinger et al., 2004). Even with increased awareness within the NHS and sepsis bundles being incorporated into care across the UK, sepsis continues to cause crisis in the NHS (Mellor, 2013; Jenkin, 2014; NHS England, 2014). Reports continue to highlight a theme of inadequate communication between professionals (Churchill, Rodger, Clift, & Tuffnell, 2014, pp. 27-42; NHS England, 2015). A maternity specific report (Knight et al., 2014) highlights that early recognition and intervention with suspected sepsis will save lives and reduce morbidity and mortality in the postpartum patient group.

It could also be argued that a key failing in the fight against sepsis is lack of public awareness. A 2015 survey found that 42% of the public in Great Britain had not heard of the term ‘sepsis’ and that 32% of respondents did not know whether sepsis was a medical emergency or not. They also found that in a large majority of sepsis cases there is a delay in presentation and admission to hospital due to patients seeking advice later than they should have (Goodwin, Srivastava, Shottom, Butt, & Mason, 2015).

Failures in leadership, failure to put patients first and failures in cohesive team working have been identified in the NHS’s failure to achieve healthcare goals (O’Neill, 2013; NHS England, 2013). To overcome this, working inter-professionally with other services and engaging with service users would add alternative viewpoints and experiences. This would enhance development and user experience and the benefit of shared ideas will increase innovation (Meads et al., 2005). I would do this through multidisciplinary meetings, questionnaires to service users, user involvement of redesigning process maps. Gathering patient experiences via feedback, complaints, serious incidents and patient and staff satisfaction surveys are also excellent sources to help identify underlying issues.

While there is a need to ensure public awareness is raised this must be balanced against the risk of creating excessive anxiety in response to symptoms which will, in most cases, not develop into sepsis. NICE guidelines (2016) provide an overview of what high quality care should look like for sepsis and my SI will support the system in achieving care excellence by raising awareness in vulnerable postnatal women.  With any communication development it is essential to ensure consistent information in line with national policy (HQIP 2015). I need to present a robust proposition for the change, evidencing the need and demonstrating that practicalities have been considered and that the change is manageable using Storey & Holti’s HLM (2013) leadership elements to provide purpose, motivating others to work effectively and  focussing on improvement.

A root cause analysis during the plan phase would help identify all issues that can be improved and to achieve this I would use diagnostic tools such as a process map (see appendix 5). This would provide a clear visual that identifies inefficiencies and unnecessary steps. Multidisciplinary stakeholders as well as service users would be engaged and involved in designing an improved process (Trebble, Hansi, Hydes, Smith, & Baker, 2010). I would also use questionnaires and surveys to gather qualitative data. Whilst this method may be criticised as less scientific than quantitative data (Mauk, 2014), within caring professions, it is essential for increasing knowledge from personal experiences  (LoBiondo-Wood & Haber, 2013).

Healthcare staff can also be resistant to change, for example, when they do not understand the reasons for changes or they can not envisage the benefits or they perceive a negative impact on their role. To overcome this, involvement of staff in the inception and implementation of the changes will identify behavioural resistance that will need to be addressed (Bowers 2011). By involving stakeholders who provide and use the services that are being improved this creates a sense of involvement, ownership and common purpose.

I would anticipate further PDSA cycles to refine the SI and adapt changes from feedback to ensure fit-for-purpose solutions are developed (Taylor et al., 2013). Future cycles could also develop innovation for quality (HQIP, 2015). I would need to ensure that the intervention is both relevant and effective for local women (Amoah & Appiah-Sakyi, 2013), examples for further cycles could be development of alternative language stickers specific to women’s needs.

During the PDSA cycles I would need a means of identifying issues and risks and a way to mitigate against those so I would create a log of these. Brainstorming is excellent for identifying potential risks and the logs should be maintained and reviewed regularly though the life cycle of the project. (NHS Institute for Innovation and Improvement, 2011).

A Six Sigma process (HQIP 2015) utilises a DMIAC framework (define, measure, analyse, improve and control) and is an alternative option for change management. However, I have not used this in this instance as six sigma is more appropriate and effective if you were looking to improve a clear stepped process, for example, appointment system improvements and where there is waste in the system and resources to redirect.

I would require a sponsor and advocate for the project so would approach the Postnatal Lead for midwifery in my Trust. Through a collaborative approach and sponsor involvement decisions can be made on the next steps or the decision can be made to stop the changes if they are found to be ineffective. Key performance and quality indicators can be defined in agreement with stakeholders and as with any change I would need to agree and gather data to identify future trends and improvements.

Once the project is complete, sharing the learning experience (both good and bad) with colleagues and other department is a key aspect of SI. This helps the organisation make the most out of learning from the experience of completed projects.

Through the process of planning this service improvement and through developing my action plan below, my awareness of collaborative practice has increased. I have assessed myself at level 3 on the ICF R4. Colleagues and service users will bring a different perspective and by working together we can promote patient centred care, leading to improved service user satisfaction. Pilot schemes, clear objectives and robust planning is required to avoid potential wasted costs, with factors such as local demographics and patient choice taken into account prior to implementation to maximise successful uptake. A collective leadership approach can be useful in increasing motivation and innovation, with all members’ voices being heard as this will ultimately benefit service users.