Arulkumaran, S

Chandraharan, E

E Chandraharan

S Arulkumaran

Crossref

Ceylon Medical Journal

The role of clinical dashboards in improving patient care: experience with the ‘Maternity Dashboard’

St George's Online Research Archive

83Vol. 61, No. 2, June 2016PerspectiveWhat is the Maternity Dashboard?The ‘Maternity Dashboard’ is a clinical performanceand governance score card which enables monitoring ofvarious pre-selected parameters at a regular (monthly)interval. Local, regional or national goals or benchmarksare used to compare the current performance againstexpected standards. This would help not only to identifyand promote areas of good clinical practice to safeguardpatient care in maternity service, but also may help detectand rectify areas that need improvement. Rarely, theMaternity Dashboard may help identify unsafe clinicalpractice. A good practice series on the MaternityDashboard has been produced by the Royal College ofObstetricians and Gynaecologists (RCOG) and this wassubsequently recommended by the Chief Medical Officerin the UK [1, 2].How to choose the parameters to be monitoredThe aim of the Maternity Dashboard is to ensurethat the principles of clinical governance are safeguardedin daily clinical practice. Clinical governance refers to theframework through which healthcare organisations areexpected to safeguard good clinical practice whilecontinuously improving care so that clinical excellencewould flourish [3]. In addition to ‘preselecting’ a group of‘general’ parameters that would facilitate comparison ofperformance with other (similar) maternity units (such asnormal birth rate, caesarean section rate and instrumentalvaginal birth, and induction of labour rates, as well as therate of massive obstetric haemorrhage), locally determinedparameters to gauge the performance of the maternity unitare equally important. These local parameters need to beselected by the multi-disciplinary team (such as theObstetric Risk Management team) with input fromneonatologists, anaesthetists and user groups. Theselocal parameters should reflect areas of clinical care thatrequire improvement, based on clinical observation. Forexample, if there is an observed increase in the rate ofThe role of clinical dashboards in improving patient care: experiencewith the ‘Maternity Dashboard’E Chandraharan, S ArulkumaranCeylon Medical Journal 2016; 61: 83-85             DOI: http://doi.org/10.4038/cmj.v61i2.8291emergency caesarean sections or third degree perinealtears the clinical practice needs to be monitored to identifycontributing factors such as errors in fetal monitoring orfailed instrumental deliveries. This may help identify a‘training issue’ with regard to instrumental vaginalbirths that could be easily rectified by conducting ‘one toone’ hands on training. Similarly, monitoring patient‘complaints and compliments’ may identify areas inmaternity service, which need to be improved.Once compliance with the ‘locally set’ standard hasbeen achieved and monitored for some time, it may beremoved from the Maternity Dashboard and new para-meters may be considered for monitoring. It is importantto use the Maternity Dashboard as a ‘dynamic’ clinicalgovernance tool to monitor evolving risks and perfor-mance issues in a maternity unit. To ensure a systematicapproach, individual parameters may be grouped underbroad categories (e.g. ‘clinical activity’, ‘workforce’, ‘riskmanagement’ and ‘responsive care’) on the MaternityDashboard.How to set the ‘standards’ or ‘goals’It is important to set a ‘gold standard’ or ‘goal’ foreach parameter that is monitored on the MaternityDashboard as it will help assess the quality of maternitycare provided and to identify shortcomings, if any.National, local or evidence-based guidelines may be usedto set the thresholds for these standards. One may modifythe National Standards to reflect local case mix orpopulation characteristics. For example, a tertiaryinstitution that delivers care to a high-risk population orreceives in-utero transfers for complex maternal and fetalconditions may have a higher rate of neonatal morbidityand mortality when compared to a ordinary institution.Individual maternity units should set upper and lowerthresholds for each of the standards to assess performanceagainst the set standards. A suggested approach is to usethe ‘traffic light’ system with green (to indicate when theDepartment of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.Correspondence: EC, e-mail: <edwin.c@sky.com>. Received 8 March 2016.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the original author and source are credited.84 Ceylon Medical JournalPerspectivegoals are met), amber (to indicate that the goals are notmet i.e. above the lower threshold, but still within the upperthreshold) and red (when the upper threshold is breached).Such a colour-coded system may give an immediate visualfeedback for providers, commissioners and users of thematernity service to understand the performance of thematernity unit easily.Collection of dataThe data should be reliable and could be obtainedfrom software systems (Euroking, Datix) or may have tobe collected manually. It is vital to cross-check the datawith the operation theatre book or the labour wardadmissions for accuracy and relevance. Data on patientcomplaints and compliments could be obtained from theComplaints Department or patient advisory and liaisonservice (PALS). A strong clinical leadership and ownershipis essential to ensure that the data disseminated throughthe Maternity Dashboard are reliable, relevant and are ofa very high quality.Suggested actionsIf a parameter scores amber, it requires a closerscrutiny and necessary action should be taken to bringthis parameter back to green. A closer observation of theparameter to identify any trends in subsequent monthsmay be all that is required. However, frequent or repeatedambers in any single parameter should necessitatecorrective action to avoid deterioration to red in sub-sequent months. A parameter that scores red requiresurgent action, as it has breached the upper limit of thelocally set standard. It may pose an impending threat topatient safety or adversely affect the quality of maternitycare provided.Our experienceThe Maternity Dashboard was introduced at St.George’s Hospital, London, UK in January 2007, as a toolto monitor various aspects of clinical governance and tohelp improve patient care and outcomes [4]. Lessons learntand advantages we had are given below.a. Dissemination of informationIn our experience, The Maternity Dashboard has beena useful tool to disseminate information about theoverall performance of the maternity unit to all staff,management, commissioners and users of the service.The Maternity Dashboard is sent via email to the leadsof clinical areas for dissemination to all staff, trustmanagement including our chief executive, localcommissioners as well as to our ‘user representatives’,every month. It is also widely discussed in our multi-disciplinary meetings as well as at our MaternityServices Liaison Committee (MSLC) meeting on amonthly basis.b. Safeguarding good clinical careThe Maternity Dashboard helped our team toappreciate areas of good practice such as our lowemergency caesarean section rate, failed instrumentalvaginal delivery rate and the hypoxic ischaemicencephalopathy (HIE) rate.c. Continuously improving clinical careThe Maternity Dashboard was instrumental in helpingus to identify and scrutinise clinical areas that scoredamber or red. Following an observed increase in therate of third degree perineal tears in 2007, we conductedan audit, which revealed that the majority of thesewere associated with instrumental vaginal birthsinvolving a single clinician. Following measures thatwere put in place to safeguard patient safety, whilesupporting and providing ‘one to one’ training to theclinician concerned, this parameter returned to greenin subsequent months after this intervention. 'One toone' hands-on training on operative vaginal births wereoffered for all obstetric trainees to avoid recurrence.d. Rectifying errors in systems and processesThe Maternity Dashboard has been a good ‘evidence-tool’ in our arguments to improve our local facilities,staffing levels and our resources. We were able toshow the trust management and local commissionersabout the increasing number of bookings, births,shortfalls in midwifery and obstetric staffing levels, aswell as patient feedback by regularly monitoring andreporting these parameters through our MaternityDashboard [5].e. Ownership and engagement of the multi-disciplinaryteamThe Maternity Dashboard has offered us an excellentopportunity to interact as a multi-disciplinary team andto identify areas of excellent clinical practice as well asareas that needed improvement. Monthly disseminationof data has helped the members of the multi-disciplinaryteam to understand and appreciate areas of goodpractice and the challenges faced by various sectorswithin our maternity service.Potential challengesMaternity Dashboard requires individual as well ascollective ownership and leadership to continuouslyimprove patient care and outcomes. Significant timecommitment and good quality data are important. Settingthe goals requires a multi-disciplinary input. Although itis desirable to accommodate the requests of every memberof the team, it is also vital to ensure that the MaternityDashboard is not overloaded with too many parameters.85Vol. 61, No. 2, June 2016PerspectiveOtherwise, it may become just another ‘paper exercise’leading to the loss of engagement with the stakeholders.Senior management team should allocate both time andresources to ensure the successful implementation andcontinuation of the Maternity Dashboard.ConclusionsClinical dashboards or ‘score cards’ help monitorperformance against set standards or goals and thereby,may help safeguard good clinical practice and helpcontinuously improve outcomes. Our experience with theMaternity Dashboard during the last eight years at St.George’s University Hospitals NHS Foundation Trust,London demonstrates that the Maternity Dashboard isan invaluable tool to rectify staffing and resource issues,monitor performance and to continuously improve patientcare and outcomes [6].Conflicts of interestsThere are no conflicts of interest.References1. Royal College of Obstetricians and Gynaecologists.Maternity Dashboard: Clinical Performance andGovernance Score Card. Good Practice Series No. 7. RCOGPress. Jan 2008.http://www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card2. Department of Health. On the State of Public Health: AnnualReport of the Chief Medical Officer 2006. Chapter 6:Intrapartum-related deaths: 500 missed opportunities.London: The Stationery Office; 2007 www.dh.gov.uk/en/Publicationsandstatistics/Publications/ Annual Reports/DH_076817.3. Chandraharan E, Arulkumaran S. Clinical Governance.Obstetrics, Gyn Reproductive Med 2007; 17: 222-4.4. Chandraharan E, Sutton J, Beattie J, Arulkumaran S. Therole of the ‘Maternity Dashboard’ in improving patientcare: 2 year experience at a tertiary centre. Int J GynecolObstet 2009; 107 (suppl2): S139.5. Royal College of Obstetricians and Gynaecologists. SaferChildbirth: Minimum Standards for Organisation andDelivery of Care in Labour. Midwifery Staffing Levels.London: RCOG Press; 2007. www.rcog.org.uk/resources/public/pdf/safer_ childbirth_report_web.pdf6. Chandraharan E. Clinical Dashboards: do they actually workin practice? a 3-year experience with the MaternityDashboard. Invited Commentary. Clin Risk 2010; 16:176-82.

The role of clinical dashboards in improving patient care: experience with the 'Maternity Dashboard'.

Abstract

Similar works

Full text

Available Versions

Crossref

St George's Online Research Archive