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Skip to 0 minutes and 13 secondsDR ELLIOT MAIN: Now that we've explored the many quality and safety issues that we have in maternity care, let's bring it all together by addressing how to go about actually improving care. This can be quite challenging as it often involves changing actual condition practices. But we are now supported by a new field of implementation science. We will explore how these principles can be integrated into projects for improving maternity care. Implementation of change is the hardest part of our journey. Even when there are national guidelines, it often takes too long to put them into widespread practice. There is now general recognition that many advances in care are "lost in translation" before actual adoption.

Skip to 0 minutes and 59 secondsThe rest of this presentation is about how to shorten this timeline. In this presentation, we take a practical approach addressing the who, what, why, and how as well as additional cross-cutting issues, such as sustainability. For each section, we will provide key references that provide further detail. Worldwide, obstetric haemorrhage remains the number one cause of maternal death, and in high-resource countries it is far and away the leading cause of severe maternal morbidity. And it is common, affecting at least 2% to 5% of women giving birth. We use examples from recent large-scale haemorrhage QI (quality improvement) projects to illustrate our principles. These principles are applicable to both large and small projects or collaboratives, and in both high- and low-resource settings.

Skip to 1 minute and 45 secondsAfter a needs assessment, one of the first steps is to identify what you actually plan to implement. Resources can be presented in several different ways. Safety bundles are a collection of general steps that we hope to accomplish, essentially a checklist. These are often created by multidisciplinary expert teams, but are designed to be individualised by local facilities to match the resources available. QI toolkits represent a collection of examples, best practices, policies, procedures, protocols, order sets, and other resources that can be used to jump start the implementation process at your hospital. The references shown are from national maternal safety projects in the United States. A driver diagram is a useful way to organise your thoughts before undertaking a QI project.

Skip to 2 minutes and 35 secondsThis is an example of a partial driver diagram for obstetric haemorrhage used in the US AIM project. After establishing a SMART goal that gives a definite target and timeline, primary and secondary drivers are laid out. These are linked to detailed action steps to accomplish each of the drivers. There are several different approaches to constructing the driver diagram, but it is a very useful way to outline a project. The resources listed below are great reading. Identifying the team to lead the project is a very important step. Creating improvement involves engaging all disciplines from an early point in planning, and then throughout implementation. Classically, the leadership should include, at a minimum, key personnel from nursing, the medical staff and administration.

Skip to 3 minutes and 27 secondsDepending on the project, others can be added to the team. Improving haemorrhage response is as an example of a project that touches many disciplines and requires a large team. A critical step that many overlook is establishing the rationale for why we should change our unit's protocols, and why our staff should change how they are doing things. Most medical teams are inherently resistant to change unless they are provided a compelling reason to adopt a new approach. Putting the need to change in the context of maternal deaths or severe morbidities is a useful construct.

Skip to 4 minutes and 7 secondsIt is also important to address both the macro picture, such as reducing state or national mortality rates, and also to bring the reasons down locally and ideally create a personal picture for the provider. "What's in it for me" is a key concept. The hardest part of implementation is managing the actual process of change. How do we integrate the new recommendations into the usual daily practice of the nurses, midwives, and physicians. And how do we sustain these changes over time? There is great power in groups working together from different institutions and as a collaborative. This allows for sharing of ideas and strategies for overcoming barriers, as well as the peer pressure to keep up with the collaborative work.

Skip to 4 minutes and 56 secondsData, even very simple metrics, are the lifeblood of quality improvement. Leadership will need to find the right balance of enough data to keep the pressure on for change and to demonstrate progress, but not too burdensome that folks rebel and stop collecting it. Beyond the who, what, why, and how, there are a series of cross-cutting principles that are important in every QI project. Continuous feedback and learning from case reviews is important, but case reviews need to focus on systems improvement rather than assessing the judgement of individual providers. QI is, first and foremost, about improving the system of care, and only secondarily improving individuals. Communications can never be overdone.

Skip to 5 minutes and 46 secondsFrequent communications with all staff about project process, successes, and other facilities and new ideas is key for maintaining enthusiasm and progress. Early engagement of patients and families is also an important ingredient of successful projects. Lastly, the support of partner organisations is incredibly helpful. These can be professional bodies, public health groups, hospital associations, patient advocacy groups, or whoever you might think could be supportive. John Kotter at the Harvard Business school is internationally renowned for his work on identifying the key steps for leading successful change projects. The model has proven effective in many different types of businesses, including medical care. The Implementing Quality Improvement Projects Toolkit mentioned below provides great examples of application of the Kotter model to obstetric haemorrhage.

Skip to 6 minutes and 48 secondsThe eight steps neatly capture most of the elements of change management described in this presentation and together with the resources should provide you a good start for the maternity QI projects. My final word of advice is to start with a small project that can teach your team the steps and has a high chance for success. Thank you, and good luck.

How can we improve quality of care?

How can we improve quality of care at scale putting evidence into practice?

In this step Dr Elliot Main (CMQCC; Stanford) explores how Implementation Science principles can be integrated into projects to improve maternity care. Timely implementation of change is a key challenge, even where national guidelines exist, and are often “lost in translation”. Eight steps for change management and quality improvement are outlined.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine

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