I’ve worked with over 40 NHS trusts, helping them to develop quality audits to drive improvement, and they all ask me the same question: “What is everyone else doing?”
It’s a natural and sensible starting point. After all, why start from scratch when someone else has done the hard work for us?
Sharing the key questions others ask provides reassurance and a useful challenge to ensure you are not missing key aspects of quality. So it makes perfect sense to us to develop a set of best practice audits to bring together the combined expertise of our customers.
We have started by developing our maternity audits. Following the publication of the Ockenden report  and more recently the CQC’s Safety, Equity and Engagement in Maternity Services , it made sense to focus on maternity and see how well the questions typically asked address the quality issues raised in recent reviews.
Missing questions: missing a trick?
We reviewed over 270 maternity audits with over 1,300 questions spanning the pathway from antenatal and community to labour, postnatal and neonatal care settings. This, though by no means comprehensive, does illustrate some common themes:
- Documentation focus: The majority centred on labour wards and focused heavily on documentation of observations and escalation. Questions such as:
“Are all appropriate observations completed on partogram inc BP, Temp, pulse, O2 saturation?”
“Is there evidence of appropriate escalation according to observations recorded on MEWs chart over the last 4 hours?
Documentation provides fantastic evidence but looking through many case notes, paper or electronic, can be tedious and time consuming, particularly if they ask several “tick box” type questions. It’s more engaging to ask staff to review (for example) risk assessments in total to ensure they provide a full picture of risks to enable appropriate care.
It’s also important to ensure you don’t bias question choice. We often start quality improvement work by focusing on inpatient settings and then roll out to community areas. But this poses the danger that inpatient themes are used as a starting point for community, leading to questions that fail to represent the key issues in community settings. Increasingly we look to work side by side with community and outpatient settings so that we truly understand quality in each setting, and then can look for commonalities.
- Duplication of effort. There are many different ways of capturing quality information – either in automated systems or for different requirements. Many questions may also be captured as part of evidence for Clinical Negligence Scheme for Trusts (CNST) so you should ensure you do not unintentionally duplicate collection. For example, questions around fetal monitoring are covered under CNST:
“Ask staff: have you had training on fetal heart rate monitoring including ongoing learning from any adverse outcomes from FHR? (Labour/midwife led unit)”
- Missing questions: Some important issues raised in Ockenden and CQC Safety, equity and engagement reports were not covered in any audits, for example:
Identifying and managing complex pregnancies suggested questions:
“Review 3 patient notes for complex pregnancies: is there evidence of involvement of the specialist and agreement between the woman and the specialist team on care plan?”
“Ask staff: can you tell me when you should call a consultant in from home?”
Staff training and working together:
“On your last training session, were there staff from other disciplines involved? Eg obs/gyn and midwives?”
“Is your obstetric lead/midwifery lead visible and accessible?”
Person centred care:
“Do you feel that your concerns for mothers/babies are always listened to?”
“Can you explain how your department ensures continuity of care for BAME/CALD or women in deprived areas?”
This raises a common theme and it’s one worth exploring as we look at best practice audits. They need to keep relevant. It’s often said that “insanity is doing the same thing over and over again and expecting different results”. So if we are not seeing an improvement in quality, we should go back and look at the questions. Our best practice work will not only provide a good starter set but looks to open an ongoing dialogue to ensure we continue to challenge if what we are focusing on is helping to drive improvement.
NB - CALD is a term frequently used across Australia and New Zealand and stands for 'culturally and linguistically diverse'.
- Lack of complete pathway view
The majority of audits centred around general maternity and labour wards with relatively little specific tailoring provided for antenatal, postnatal or community settings. This may mean that you do not have visibility on key quality areas specific to these settings. It also misses out on the benefits of looking across a whole pathway.
Increasingly we are working with customers to look across their entire pathway. This can help in several ways:
- By being able to understand what is important for quality care in each part of the pathway provides opportunities to pick up on risks at an earlier stage: For example, by asking questions to assess mental health at an antenatal stage will help in effective postnatal care; by identifying complex pregnancies should help ensure mothers give birth in the right setting with the right care.
- Fostering engagement between different departments. Much has been said about the drawbacks of “silo working” and the value of Multi Disciplinary Teams (“MDT”) has been recognised for years. Communication is key to addressing this, so by providing visibility across the whole pathway of what is important to each area helps the conversations and joint working develop.
- Not every service user will experience care in the same way and we should ensure that we don’t have a “one size fits all” assessment of quality.
 For more insight into pathway view of maternity, please check out our webinar we did with Norfolk and Norwich University Hospitals NHS Foundation Trust [add in link].
Above all, the key value in assessing audits is in engaging with staff and service users across the pathway. But engagement is not a one-off exercise – you need to develop a regular forum which welcomes challenge from staff and users in all roles to keep your assessments relevant and valued and if you don’t see the point in answering a question – ask!
You will never be able to assess absolutely every aspect of quality in an audit: you need to focus on what will have the biggest impact to service users and staff now. You may also want to consider having a theme for a quarter which breaks down some key areas that you want to tackle, improve them, then move the focus to a new area. And its of course vitally important that you keep your eyes and ears open to understand what issues affect quality.
How to get involved
This review has posed key questions about the effectiveness of existing quality assurance processes and made us think differently about audit: moving away from audit for assurance-sake towards audit as a tool for improvement. If you would like to learn more about our work on maternity audits, please do contact us at:
References and links.