obstetric, maternity and gynaecology services - … · 2 recommendation actions to be taken...

1

Action Plan Arising from RCPCH Evaluation

Recommendation

Actions to be taken

Timeline Responsible Person

Monitoring Progress / Current Status

Obstetric, Maternity and Gynaecology Services

Strategy and Patient safety

1 Expedite the ‘Phase Two’

business case and commence

development to provide a high

quality environment for

consultant-led maternity care and

compliant facilities for neonates.

Formally establish Phase 2 project and develop business case for Welsh Government consideration.

Initial business case by Spring 2016

Chief Executive (as SRO of Phase 2 Project Group)

BP&PAC Phase 2 Project Group established November 2015. Clinical User Groups and Project Team currently developing design specification for individual elements of project.

2 Develop a clear sustainable

strategy for obstetric, midwifery

Multi-disciplinary clinical group to

September 2016 General Manager, W&C Directorate

BP&PAC Multi-disciplinary clinical group

2

Recommendation

Actions to be taken



and gynaecology services,

prioritising patient safety, patient

access and quality of care,

building on and completing the

changes of services introduced in

August 2014. New ideas,

perhaps from a ‘task and finish’

innovation group can refresh the

team, harnessing external

support to examine new ways of

working with the support of the

local clinicians and women

be established involving consultant, midwifery and Gynaecology staff to develop strategy and prioritise innovation ideas and new practice. (Task & Finish groups to be agreed for specific projects).

established 6th January 2015.

3 Identify clinical line

management for the Directorate

to provide visible and robust

professional support, mentoring

and development to the clinical

leads for obstetrics and

paediatrics and the Head of

Midwifery. An independent

member at Board level should

have a remit of responsibility for

women's and children's issues

Acute Service operational structure to be reviewed. Independent Board member with lead responsibility as Children’s Champion to be confirmed

March 2016 In Place

Director of Operations Mr Mike Ponton

BP&PAC BP&PAC

Acute Service operational structure under current review. Proposals currently being developed. Achieved (Independent Board member identified as Children’s Champion)

4 Expand community based Plan for September 2016 General Manager, BP&PAC Multi-disciplinary

3

Recommendation

Actions to be taken



consultant and midwifery based

services at Withybush,

developing more comprehensive

EPU, EGU, day theatre, and

clinical community based

services there in line with RCOG

standards1

expansion of community based consultant and midwifery services to be developed by multi-disciplinary clinical group (referred to above).

W&C Directorate clinical group established 6th January 2015.

5 Retain provision of dedicated

transport facilities

Renew SLA for DAV for 2016/17

March 2016 Executive Director of Commissioning

BP&PAC Health Board agreement to retain DAV for 2016/17

6 Rationalise major in patient

gynaecological surgery onto one

site, if accommodation allows.

Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications

Review of capacity and service implications by June 2016

Clinical Lead, O&G (via multi-disciplinary clinical group)

BP&PAC Clinical T&F Group to be established February 2016 to assess clinical and service implications.

7 Phase out the obstetric and Clinical Task & Finish Group to

Review of capacity and

Clinical Lead, O&G (via multi-disciplinary

BP&PAC Clinical T&F Group to be

1 2013 Good Practice 15 Reconfiguration of women’s services n the UK RCOG

4

Recommendation

Actions to be taken



gynaecology out of hours

consultant rota at Withybush with

a target date of April 2016,

integrating and strengthening the

obstetric and gynaecological

consultant team at Glangwili.

be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications

service implications by June 2016

clinical group)

established February 2016 to assess clinical and service implications.

8 Review of the uptake of midwife

led care, and plan to expansion

of use by women who have been

appropriately risk assessed.

Unified patient pathways,

guidelines and clinical

governance structures must be

incorporated into all units within 6

months

Promote awareness of All Wales MLU guidelines amongst all midwifery staff. Monthly monitoring of MLU usage via Directorate. Establish database of all women who are suitable for MLU care and audit of outcome Review all supporting pathways,

March 2016 February 2016 March 2016 June 2016

Senior Midwife MLU / Community Senior Midwife MLU / Community Senior Midwife MLU / Community Senior Midwife MLU / Community

QSEAC Current MLU Utilisation Jan – Dec 2015 (22%)

5

Recommendation

Actions to be taken



guidelines and unit governance structures

9 Assurance to public of the safety

of birthing in MLU’s in line with

the All Wales Pathway for

Maternity Care; community

midwives should take a stronger

lead in this. A band 7 midwife

should be appointed to champion

a team to develop each of the

MLUs in terms of increased

usage, active birth supporters

and midwives competence and

confidence in supporting active,

non pharmacological birth.

Develop communication strategy to engage with women across Hywel Dda to promote MLU as a viable option for giving birth Responsibility of Band 7 Community midwives to be confirmed.

April 2016 March 2016

Senior Midwife MLU / Community Senior Midwife MLU / Community

BP&PAC Communication strategy to be developed by April 2016. Role and responsibilities of Community midwives to be confirmed by March 2016.

Staff Team and Leadership Development

10 Conduct medical staff job

planning to provide a unified safe

service which delivers

professional satisfaction to staff

Review and update all job plans

March 2016 General Manager W&C Directorate/Clinical Lead O&G

BP&PAC All job plans to be reviewed by March 2016

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Recommendation

Actions to be taken



across both sites.

11 Develop a programme of

opportunities for midwifery

development that reflects the

aspirations of service

developments – these should be

achieved within a 12 month

period

To be progressed in parallel with multi-disciplinary clinical group and midwifery OD programme.

December 2016 Head of Midwifery BP&PAC Multi-disciplinary clinical group established 6th January 2015. Midwifery OD programme commenced December 2016.

12 In order to meet RCoA standards

and secure future allocation of

anaesthetic trainees further

additional sessions are needed

on the labour ward.

Anaesthetic workforce development plan to be produced in parallel with HB IMTP.

Workforce Development Plan by March 2016 (Implementation plan subject to IMTP)

Service Delivery Manager, Anaesthetics

BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016

13 The multi-disciplinary training

opportunities for doctors, nurses

and midwives are considerable

and need further development. A

training lead should be identified

to ensure training is carried out

across all groups including

simulation and skills/drills.

Multi-disciplinary clinical group to review current multi-disciplinary training plan to ensure availability of appropriate skills. Identify a training lead to coordinate training

June 2016 April 2016

Clinical lead O&G / Head of Midwifery Head of Midwifery

QSEAC Multi-disciplinary clinical group established 6th January 2015. Training lead to be confirmed

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Recommendation

Actions to be taken



programme across multi-disciplinary team.

14 A programme of organisational

development should be

instigated to build team working

and a sense of ‘one service’;

across all staff groups from all

three sites including community.

This could be informed by the

Fundamentals of Care audit, and

include encouragement and time

to nurture potential future

medical leaders

Implement programme of Organisational development for clinical staff, commencing with midwifery teams before consideration of roll out to medical staff and neonatal / paediatric teams.

Commenced December 2015

Head of Midwifery QSEAC OD programme commenced.

Governance and Accountability

15 The new Band 7 maternity risk

manager should administer the

clinical governance programme

including three monthly reports

with action plans to the Trust

Board and clinical directorate

meetings

Confirm substantive appointment of interim Band 7 postholder within current resources

March 2016 General Manager QSEAC Quarterly reports to be considered via HB Q&S structure from March 2016

8

Recommendation

Actions to be taken



16 The maternity dashboard, should

be reviewed by the directorate

Quality and Safety Committee

quarterly for review and

appropriate action. Review of

compliance with the RCOG

Maternity Standards should be

undertaken immediately and

upon publication of the new

standards expected during 2016

Ensure implementation of new All Wales Maternity Network Dashboard and include as standing agenda item at Directorate Q&S meeting. Review compliance of new standards once published

January 2016 Once published

Head of Midwifery O&G Clinical Lead/General Manager W&C directorate

QSEAC

All Wales Maternity Dashboard report to be considered at W&C Directorate Q&S Committee in January 2016. Publication of new standards awaited.

17 Review of the midwifery

workforce establishment using

Birthrate Plus acuity tool should

be completed immediately and at

least every 2 years.

Confirm HOMS recommended Birthrate Plus assessment tool BR+ exercise to be conducted following confirmation of recommended tool.

March 2016 To commence upon confirmation of HOMS recommended assessment tool.

Head of Midwifery Head of Midwifery

QSEAC

Confirmation of recommended assessment tool awaited via HOMS. To commence upon confirmation of HOMS recommended assessment tool.

9

Recommendation

Actions to be taken



18 Quality Improvement projects

such as the Productive Ward,

Releasing Time to Care should

be used to involved all groups of

staff in the quality improvement

programme

Quality improvement projects to be prioritised by multi-disciplinary clinical group.

From February 2016.

Head of Midwifery QSEAC

Multi-disciplinary clinical group established 6th January 2015.

Public Engagement

19 The Maternity Service Liaison

Committee should be re instated

with membership drawn from

local recent service users.

Additionally the service should

seek out ways to engage with the

local families living in the three

counties.

Programme of MLSC meetings to be re-established. Women & Children’s Communication & Engagement Strategy to be developed.

April 2016 April 2016

Head of Midwifery Head of Communications & Engagement

QSEAC Programme of MLSC meetings to be confirmed. W&C Communications & Engagement Group established 14th December 2015.

20 A social media campaign should

promote positive birth

experiences / normal birth in

various media and establish a

user group to provide feedback

and advice on improving take-up

of the MLU

Women & Children’s Communication & Engagement Strategy to be developed.

May 2016 Head of Communications & Engagement

QSEAC W&C Communications & Engagement Group established 14th December 2015.

10

Recommendation

Actions to be taken



21 Ensure all staff in contact with

expectant parents are fluent in

the service arrangements,

choices available for women,

thresholds for transfer and

outcomes.

Refresher training /update on services to be provided to all midwives and Health Visitors

March 2016 Head of Midwifery BP&PAC W&C Communications & Engagement Group established 14th December 2015. Revised communications pack to be prepared.

22 Facilities for birth partners,

whose partner may not be in

established labour, to rest and

obtain a hot drink should be

available 24 /7 at Glangwili.

Establish an interim facility pending Phase 2 redevelopment.

March 2016

Senior Midwife Acute

QSEAC Interim facility identified (pending Phase 2 redevelopment). Minor refurbishment works being undertaken.

Neonatal Service

Strategic Planning and patient safety

23 Implement the ‘Phase 2’

developments to provide

adequate accommodation for

neonates and families.

Formally establish Phase 2 project and develop business case for Welsh Government

Initial business case by Spring 2016

Chief Executive (as SRO of Phase 2 Project Group)

BP&PAC Phase 2 Project Group established November 2015. Clinical User

11

Recommendation

Actions to be taken



consideration.

Groups and Project Team currently developing design specification for individual elements of project.

24 Gain commitment and support

from the Health Board and The

Wales Neonatal Network for a

strategic plan for neonatal care

towards designation of the unit

as an LNU.

Agree a joint development plan with the Wales Neonatal Network

Agreement of plan by May 2016

Clinical Lead, Children’s Services

QSEAC All Wales Neonatal Standards Compliance Report (as at Sept 2015) published Dec 2015. Wales Neonatal Network Annual Compliance Visit 8th January 2016 – report awaited. Further All Wales Neonatal Standards Compliance Report (as at Dec 2015) expected March 2016 – will inform joint

12

Recommendation

Actions to be taken



development plan.

25 Conduct a training needs

analysis amongst medical staff

for competencies pertinent to

operation as an LNU and a plan

to meet those needs

Training needs analysis to be undertaken as per Wales Neonatal Standards. Outcome to inform joint development plan with Neonatal Network as above

April 2016 May 2016

Neonatal Clinical Lead

QSEAC To commence February 2016.

26 With facilitated OD, continue to

develop team cohesion and a

sense of ‘one service’

Extend Organisational Development programme to Neonatal Service clinical staff, following initial phase with midwifery teams.

September 2016 Directorate Nurse QSEAC Neonatal Organisational Development programme to commence September 2016.

27 Include EMRTS procedures into

MLU protocols at WGH

MLU protocol to be revised to reflect EMERTS availability.

February 2016

Head of Midwifery

QSEAC

Policy currently being reviewed for operational approval via

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Recommendation

Actions to be taken



Directorate Q&S Committee February 2016.

28 Strengthen and formalise clinical

meetings with Singleton,

reviewing all cases weekly and

documenting discussions and

actions

Programme of review meetings with Singleton NICU to be arranged.

February 2016 Neonatal Clinical Lead

QSEAC Joint HDd / ABM Neonatal review meeting scheduled 12th February 2016.

29 Ensure the Wales Neonatal

network guidelines are available

to all staff working on the unit

Ensure availability of Wales Neonatal Network Guidelines via shared drive on the Neonatal Unit.

January 2016 Senior Nurse (Quality Assurance), Neonates

QSEAC Achieved (guidelines available via shared drive).

30 Review protocols and skills for

emergency out of hours

stabilisation given that CHANTS

is not a 24-hour service.

Review protocol(s) for emergency out of hours stabilisation to support management of babies pending arrival of CHANTS retrieval service.

January 2016 Neonatal Clinical Lead / Senior Nurse (Quality Assurance), Neonates

QSEAC Achieved (Neonatal Network protocols for premature babies available on Unit. All supporting resuscitation guidelines are current).

14

Recommendation

Actions to be taken



31 Initiate and support opportunities

for the neonatal leads to join

sessions at the Singleton to help

sustain and further develop their

neonatal expertise.

Agree programme of joint rotations / visiting sessions with Singleton NICU team.

April 2016 Neonatal Clinical Lead

QSEAC Initial discussions commenced between Medical Directors. Further discussion scheduled between joint Neonatal teams 12th February 2016 (Joint HDd / ABM Neonatal review meeting).

32 Ensure that all consultants

providing out of hours cover have

some daytime involvement on

the neonatal unit which could be

attendance at the weekly grand

round as a minimum

Remove all Community Paediatricians from acute on-call rota.

December 2015 Clinical Lead Children’s Services

QSEAC Achieved (all consultants providing out of hours cover of Neonatal Unit have planned daytime sessions on Unit as part of Consultant of the Week rota)

33 Revisit the BLISS audit with

service users and develop an

action plan ‘you said-we did’

Parent Support Group to be established to review audit and develop supporting action plan.

April 2016 Senior Nurse (Quality Assurance), Neonates

QSEAC Parent Support Group to be established by April 2016.

15

Recommendation

Actions to be taken



34 Improve accommodation

arrangements for parents and

communicate them clearly,

perhaps utilising the CHC to

audit awareness

Promote availability of current facilities / services for all parents pending improvement of facilities as part of Phase 2 re-development.

Immediate

Senior Nurse (Quality Assurance), Neonates

QSEAC Achieved (profile of parents’ accommodation / transport needs included in Unit and handover meetings and awareness raised re supported transport arrangements).

Paediatrics and Emergency care

Emergency Pathway

35 Clarify the governance, decision

making and pathway

arrangements for paediatric

attenders out of hours,

particularly the relationships

between paediatrics, ED and the

Out of Hours GP service so

patients, public and referrers are

clear about whom to refer to at

different times of day. and what

telephone support is available

Review current policies and protocols

December 2015

Clinical Lead, Children’s Services.

QSEAC Policy review meeting held 18th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee.

16

Recommendation

Actions to be taken



from the Glangwili paediatricians

to diagnose, treat and discharge

locally where safe and

appropriate.

36 Continue with the relocation of

the Withybush PACU nearer to

the ED

Progress PACU relocation in parallel with redevelopment of WGH.

Spring / Summer 2016

General Manager / WGH Clinical Lead

BP&PAC PACU Relocation plans being progressed via WGH CDU / Ward 10 Project (relocation expected late Spring / early Summer 2016)

37 Audit WAST out of hour

paediatric decisions around 999

destination, with a group

including anaesthetists, WAST,

paediatric and ED staff and

revisit criteria/refresh training as

necessary

Undertake audit in conjunction with WAST and relevant clinical teams

July 2016


QSEAC Audit specification to be agreed by March 2016.

38 Provide a further 12 month

extension to the DAV to March

2017 reviewing again once other

changes have been made

Renew SLA for DAV for 2016/17

March 2016 Executive Director of Commissioning

BP&PAC Board agreement to retain DAV for 2016/17

39 Ensure there are adequately

qualified staff with paediatric

resuscitation skills available at all

Training / Skills development programme to be

From April 2016 Clinical Lead WGH (with support from HB Resuscitation

QSEAC Programme to be agreed from April 2016.

17

Recommendation

Actions to be taken



times at WGH, perhaps through

a programme of training and

skills development for the

anaesthetic team with rotation to

other units to maintain skills. The

paediatric team should play a

leading role in overseeing

arrangements

arranged

Training Team & Paediatric Team)

40 Strengthen nurse staffing in ED

through urgent appointment of

Registered Children’s Nurses

(one per shift) to provide general

paediatric expertise. Longer

term consider development of

Emergency Nurse Practitioner

(ENP) roles, including nurse

prescribers, and a 5-year plan for

training and retention.

ED workforce development plan to be produced in parallel with HB IMTP.

Workforce Development Plan by March 2016 (Implementation Plan subject to IMTP)

Joint planning required between:

• Lead Nurse, WGH site

• Directorate Nurse, Children’s Services

• Lead Nurse, Unscheduled Care

BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016

41 Ensure that all staff who advise

members of the public are aware

of the correct clinical pathway to

access early treatment and safe

transfer.

Review current policies and protocols and communicate to relevant staff.

December 2015

Clinical Lead, Children’s Services.

QSEAC Policy review meeting held 18th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee and updated policies to be re-

18

Recommendation

Actions to be taken



issued with supporting communications / information.

Paediatric Care

42 Formally merge the paediatric

consultant team and remove the

out of hours cover for Withybush

with a target date of April 2016

once the paediatric, nursing and

management team are sure that

appropriate emergency

arrangements (training access

transfer) are in place. This

assurance should be supported

by monitoring of all attendances

out of PACU operating hours to

ensure appropriate case

management occurred, and

identify any incidents resulting

from the changes.

Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications

Review of capacity and service implications by June 2016

Clinical Lead, Children’s Services (via multi-disciplinary clinical group)

BP&PAC Clinical T&F Group to be established February 2016 to assess clinical and service implications.

43 Redesign job plans for

consultants and speciality

Review and update all job plans

March 2016 General Manager W&C Directorate/Clinical

BP&PAC All job plans to be reviewed by March 2016

19

Recommendation

Actions to be taken



doctors to deliver Facing the

Future standards including

consultant cover at peak times

Lead, Children’s Services

44 Ensure there is sufficient

outpatient capacity for all local

children to be seen in clinics at

Withybush. This would be for

general paediatric problems and

also subspecialty clinics.

Review paediatric outpatient demand / capacity plans (to account for acute / community paediatric and subspecialty / visiting clinics)

March 2016

Service Delivery Manager, Paediatrics

BP&PAC Replacement Paediatric Service Delivery Manager to take up post 25th January 2016.

45 Ensure that most investigations –

uncomplicated radiology and

ultrasonography, venupuncture

and ECG – can be undertaken at

Withybush

Review & Audit current availability of diagnostics and uptake at WGH for paediatric patients

June 2016


BP&PAC Audit of access to investigations to commence March 2016.

46 Develop a vision for PACUs as a

single service for the Health

Board

Strategy for future development of PACUs to be developed (including review of operational policies for consistency)

September 2016 Clinical Lead, Children’s Services / Directorate Nurse Children’s Services

QSEAC PACU Review T&F Group to be established February 2016 to progress development of strategy.

20

Recommendation

Actions to be taken



47 Review, with primary care

colleagues, compliance with the

Facing the Future Together for

Child Health standards and

establish a plan for

implementation and audit.

Establish task and finish group with primary care to review standards and plan for implementation.

October 2016 Clinical Leads Children’s Services / Primary Care

QSEAC Task & Finish Group to be established March 2016.

48 Continue development of the

High Dependency service as part

of the network with Cardiff as the

local PICU, conforming to

national standards2

Review current PHDU service against national standards and identify areas for improvement.

July 2016 Paediatric HDU Clinical Lead

QSEAC Paediatric HDU lead appointed to lead review work

49 Support investment in the

Community Children’s Health

service towards compliance with

the RCN3 and RCPCH4 guidance

for community child nursing.

There is an urgent need for

recruitment of Consultant

Community Paediatricians

Develop a clear plan for community children’s services Continue recruitment efforts to fill current

July 2016 From January 2016

Directorate Nurse Children’s Services Clinical Lead, Children’s Services

BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016 Recruitment efforts continuing. Locum appointment

2 RCPCH/PICS Time to Move On 2015

3 NHS At Home – developing Community Children’s Nursing DH England 2011

4 Facing the Future Together for Child health – RCOCH 2015

21

Recommendation

Actions to be taken



vacancies. scheduled to commence January 2016.

50 Develop the roles of specialist

nurses, for example in epilepsy,

asthma/ respiratory.

Review current profile of specialist nurses and identify priority areas for development

March 2016 Directorate Nurse Children’s Services

QSEAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016

51 Review scope of on-call activity

and maximise the role of nurses

to help reduce pressure on

doctors, including development

of a criteria led nurse discharge

programme.

Review on call activity and demand Identify opportunities for extended roles for nursing staff in support of medical teams and discharge pathways.

May 2016 June 2016

Clinical Lead, Children’s Services Directorate Nurse, Children’s Services

BP&PAC Audit of on-call activity to undertaken March/April 2016. Task & Finish Group to be established February 2016

Strengthen user involvement and public engagement

22

Recommendation

Actions to be taken



52 Develop ongoing

communications and

engagement plan through the

new committee to include

• Pushing positive birth stories

to the media and staff

• Proactive analysis of the ‘did

we deliver’ materials

• Engagement of GPs with

clear information about

referral criteria




53 Suggest CHC or user group be

invited to audit/survey fathers

about current arrangements and

their experience of care.




54 Re-establishment of the user

group and MSLC

Programme of MLSC meetings to be re-established. Women & Children’s Communication & Engagement Strategy to be developed.

April 2016 April 2016

Head of Midwifery Head of Communications & Engagement

QSEAC Programme of MLSC meetings to be confirmed. W&C Communications & Engagement Group established 14th December 2015.

obstetric, maternity and gynaecology services - … · 2 recommendation actions to be taken...

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