Bailey, Elizabeth

Fryer-Croxall, Claire

As a large NHS teaching trust we see 6,000 women a year who birth with us. Newly appointed as a modern matron, I noted that poor experience on our postnatal ward has always been a key issue in the complaints we receive and from the feedback that our women give to us. The ImPosE (improving postnatal experience) project was launched in December 2013. This brought together members of the multidisciplinary team who were committed to developing our postnatal ward and improving it for our women and their families. We used a quality management approach, putting 'customer' experience at the core, and implemented a varied package of changes as directed by feedback from service users

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  A woman-led approach to improving postnatal care  Claire Fryer-Croxall and Elizabeth Bailey  Published PDF deposited in Curve February 2016  Original citation:  Croxall, C. and Bailey, E. (2014) A woman-led approach to improving postnatal care. The Practising Midwife, volume 17 (7): 21-3  Medical Education Solutions  Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders.  CURVE is the Institutional Repository for Coventry University  http://curve.coventry.ac.uk/open  Responding to negativefeedback from serviceusers specifically aboutpostnatal care, ClaireFryer-Croxall andElizabeth Baileydescribe the steps taken inCoventry andWarwickshire to improvesupport for women andtheir familiesA woman-led approach toimproving postnatal careIntroductionIt has long been recognised that postnatal carehas been the ‘Cinderella service’ in maternitycare (Wray 2006; Barker 2013) and, despiterepeated directives for improvement, fromChanging childbirth (Department of Health(DH) 1993) through to Maternity matters (DH2007), women are more likely to rate postnatalcare less favourably than other aspects of care(Brown et al 2005). For example, surveys by theNCT (Singh and Newburn 2000; Bhavnani andNewburn 2010) found that women want moremidwifery time, information and consistentadvice in the postnatal period. The closeemotional attachment of both parents at thisspecial time can be left unacknowledged, andsupport from midwives is of great importanceto the families (Ellberg et al 2010).ComplaintsFrom reviewing the complaints received overthe previous 12 months at University HospitalCoventry and Warwickshire (UHCW), it wasclear that this was no exception. During a pilotof the Friends and family test (FFT) (NHSEngland patients and information directorate(NHS EPID) 2013) findings revealeddisappointing scores about postnatal care. TheTrust’s pre-existing Impressions survey, whichinvites open comments and feedback, alsohighlighted that women felt alone,unsupported and part of a process rather thanhaving a sense of woman/family-centredness.This background context provided an opportunityto implement a strategy to improve women’sexperience of postnatal care in a way thatwould be embraced by staff and women.SUMMARY: As a large NHS teaching trust we see 6,000 women a year who birth withus. Newly appointed as a modern matron, I noted that poor experience on our postnatalward has always been a key issue in the complaints we receive and from the feedbackthat our women give to us. The ImPosE (improving postnatal experience) project waslaunched in December 2013. This brought together members of the multidisciplinaryteam who were committed to developing our postnatal ward and improving it for ourwomen and their families. We used a quality management approach, putting ‘customer’experience at the core, and implemented a varied package of changes as directed byfeedback from service users.Keywords ImPosE, listening, improve, quality management, postnatal careAuthors Claire Fryer-Croxall, modern matron and supervisor of midwives and ElizabethBailey, midwife research fellow, both at University Hospitals Coventry and WarwickshireNHS TrustWomen are more likelyto rate postnatal careless favourably thanother aspects of care>>21The Practising Midwife | July/August 201422 The Practising Midwife | July/August 2014Fifteen steps challengeAs a newly appointed modern matron in 2013,a priority activity I performed was a ‘fresh eyes’exercise on the postnatal ward in collaborationwith a maternity support worker. This was inline with the consumer-led concept of the ‘15steps’ challenge which was developed from thefollowing comment from a parent:"I can tell what kind of care my daughteris going to get within 15 steps of walkingonto a ward" (NHS Institute for Innovation andImprovement (NHS III) 2012).Features that became apparent in thisprocess included: the curtains being closedaround every bed space; staff appearing to berushed; and women not interacting with eachother. Women appeared to be alone andsearching for assistance. In addition, womendisclosed that the care they had whilst onlabour ward and in the birth centre had been‘amazing’ and that they had felt looked afterand supported; but when they were transferredto the postnatal ward they felt abandoned,alone and anxious. Some of the key issueshighlighted were about the rigid nature ofvisiting hours, delayed discharge paperwork,that there appeared to be staff shortages andthat they did not have enough help withbreastfeeding. Listening to what women tell usabout their experiences has been thecornerstone principle to making positivechanges within the maternity unit. This wasinitially an intuitive process, which was thenbuilt upon with our insights from FFT, ‘fresheyes’ and ‘Impressions’ survey data, all ofwhich informed the implementation of afocused project: ‘Impose’.ImPosE(Improving postnatal experience)We used a total quality management approachby putting ‘customer’ experience at the core ofchange (See Table 1). By following qualitymanagement principles we were able to usewhat we had learned from ‘customerexperience’ and develop a ‘process’ and‘system’ approach to ward activities, based onwomen’s journey through the ward. We lookedat changing systems or processes that had anegative impact on experience (See Table 1).Aware of the common recognised barriers tochange, namely motivation, acceptance andbeliefs, skills and practicalities (NationalInstitute for Health and Care Excellence (NICE)2007), positive managerial support was offeredwith an emphasis on leadership.The ImPosE campaign was launched inDecember 2013, whereby staff attended alistening event. The campaign was shared withthe local maternity liaison support committee,and launched on Twitter. Both women andstaff were invited to comment on their ideasfor improvements. A core team of midwives onthe postnatal ward was set up to lead thechanges in line with the third total qualitymanagement principle of ‘involvement ofpeople’ (Patel 2009). In line with principles of this model,changes were made to the overall organisationof the ward’s daily activities, and a pragmaticapproach to addressing the issues raised wasapplied. There were some initial difficulties inchanging some historical practices on theward, but once people’s negative assumptionswere not realised, the changes were accepted.The overall motivation of the staff and theirsense of ownership of the changes allowed for1 Customer focusedorganisationOrganisations depend on their customers and therefore shouldunderstand current and future customer needs, should meet customerrequirements and strive to exceed customer expectations2 Leadership Leaders establish unity of purpose and direction. They should create andmaintain the internal environment in which people can become fullyinvolved in achieving the organisation's objectives3 Involvement ofpeoplePeople at all levels are the essence of an organisation and their fullinvolvement enables their abilities to be used for the organisation'sbenefit4 Process approach A desired result is achieved more efficiently when activities and relatedresources are managed as a process5 System approachto managementIdentifying, understanding and managing a system of interrelatedprocesses as a system contributes to the organisation’s effectiveness andefficiency in achieving its objectives6 ContinualImprovementContinual improvement of the organisation's overall performance shouldbe a permanent objective of the organisation7 Factual approachto decision makingEffective decisions are based on the analysis of data and information8 MutuallybeneficialrelationshipsAn organisation and its suppliers are interdependent and a mutuallybeneficial relationship enhances the ability of both to create valueTable 1 Principles of total quality managementA woman-led approach23The Practising Midwife | July/August 2014A woman-led approachthe introduction of multiple changes withinthe wider goal of improving the wholepostnatal ward experience.ChangesWard environment and organisational changes:• An open curtain policy was launched toimprove safety on the ward and toencourage women to talk to each other andshare their experiences. • A designated ‘discharge midwife’ on everyshift to host daily (10am) postnatal dischargeinformation, giving a session with a nurserynurse and to manage paperwork. Women areurged to attend this as it encourages groupdiscussion and speeds up their discharge.• The Head of midwifery has supported eightmaternity support workers to commence adiploma in health care at the local college,which is designed around postnatal care. • Ten additional midwives have been funded tocomplete a newborn physical examinationcourse at Coventry University to improve thedischarge process.Women’s suggestions influenced these changes:• Employment of nursery nurses to assistwomen with the fundamentals of newparenting.• Changes to visiting hours to enable partnersto be present all day.• Fold-away beds purchased to enable partnersto stay overnight in side rooms.• Our yearly #maternitymarch Twittercampaign focused on the postnatal area.SuccessIn just six months complaints about thepostnatal ward reduced significantly. Therepeated FFT and the Trust’s Impressions surveyhave shown a notable shift towards positiveexperiences.In line with the total quality managementprinciples of ‘continual improvement’ andmutually beneficial relationships (See Table 1),a poster has been designed and displayed inthe entrance to the ward which has photographsand contact details of the matron and theward manager, so that we can be contactedand respond more promptly (See Figure 1). The6Cs (Commissioning Board Chief NursingOfficer (CB CNO) and DH Chief Nursing Adviser(DH CNA) 2012) logo is apparent as well as theFFT, and space for ‘You said’ and ‘We did’allows feedback on how we are developing ourservice from women’s comments.ConclusionOur approach to implementing change andimproving the experiences of women on theward has been one that embraces a ‘commonsense’ rationale with communication at its coreand in line with a ‘customer service’ drivenmodel (Patel 2009). The 2014 RCM Pressurepoints campaign (RCM 2014) made manyrecommendations for maternity services, whichthe ImPosE project has, coincidentally,addressed. Of note are increased resources anddelivery of consistent evidence-basedinformation. Our approach to listening throughthe FFT and visibility on the wards of the wardmanager and modern matron will continue.We are committed to keeping dialogue openwith staff, to drive the service forward.Claire Fryer-Croxall is modern matron andsupervisor of midwives and Elizabeth Bailey ismidwife research fellow, both at UniversityHospitals Coventry and Warwickshire NHS TrustReferences Barker K (2013). ‘Cinderella of the services – thepantomime of postnatal care’. Brit Jour Midw, 21(12): 842.Bhavnani V and Newburn M (2010). Left to your owndevices – the postnatal experiences of 1,260 first timemothers, London: NCT.Brown S, Davey M and Bruinsma F (2005). ‘Women’sviews and experiences of postnatal hospital care in theVictorian survey of recent mothers 2000’. Midwifery,21: 109–126.CB CNO and DH CNA (2012). Developing the culture ofcompassionate care: creating a new vision for nurses,midwives and care-givers. NHS Commissioning Board,London: Crown.DH (1993). Changing childbirth. Part 1: report of theexpert maternity group, London: HMSO.DH (2007). Maternity matters: choice, access andcontinuity of care in a safe service, London: DH.Ellberg L, Högberg U and Lindh V (2010). ‘We feel likeone, they see us as two’: new parents’ discontent withpostnatal care’. Midwifery, 26: 463-468.NHS EPID (2013). The national friends and family test:guidance for maternity services, London: NHS England.NHS III (2012). The fifteen steps challenge quality froma patient’s perspective part of the productive careresources, London: NHS III.NICE (2007). How to change practice, London: NICE.Patel G (2009). ‘Total quality management inhealthcare’. The MIDAS Jour, 27th May 2009. RCM (2014). 24 hour signs and symptoms - advisingon the potentially life-threatening signs in postnatalcare, London: RCM.Singh D and Newburn M (2000). Women’s experiencesof postnatal care, London: NCT.Wray J (2006). 'Seeking to explore what matters to womenabout postnatal care '. Brit Jour Midw, 17(5): 204-208.Figure 1 Poster displayed in ward entrance area

A woman-led approach to improving postnatal care

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A woman-led approach to improving postnatal care

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