Transforming clinical practice and digitising pathways
It was this phrase from a patient that underscored the importance of transforming care for mothers and babies to the team at the Royal Free London group (RFL).
Separating babies from their mothers after birth has long-term detrimental effects on breastfeeding, mother-baby attachment and mothers’ mental health. Despite falling birth rates, RFL, like other Trusts, are admitting more and more vulnerable babies to neonatal units due to a range of factors. As a result, in England, a family is separated from their baby within those first few magical hours approximately every 12 minutes.
Recognising the rising trend of neonatal unit admissions, and aware of national attention, RFL have taken it as a call to action to redefine how they deliver safe, high quality care through clinical practice groups (CPGs).
Making a difference Royal Free London’s ‘keeping mums and babies together’ pathway is one of 44 such projects undertaken by the Trust to improve care quality and reduce variation.
Working together with multi-professional teams from all clinical specialties - as well as change teams, executives and, importantly, mums and dads - the pathway helped define and deliver a single, simplified, standardised pathway for term and late pre-term infants. This allows the neonatal and maternity teams to easily identify more vulnerable babies and provide enhanced postnatal care alongside their mothers.
The team admit that they purposefully set themselves ambitious goals from the outset. The CPG aimed to reduce admissions to neonatal care after 34 weeks for term and late pre-term babies.
“We thought it was too complex,” said Shanthi Shanmugalingam, neonatal consultant, “but when we engaged our teams in the problem… Together we came up with something radical that hasn’t been done anywhere else in the country.
“We brought all the guidelines together and distilled them down to form a pathway that was simple - one set of observations and monitoring for ALL babies at risk.”
Working with the wider teams across the Trust, the CPG engaged staff to find consensus and deliver a criteria-based standardised assessment tool. This would now support their most junior team members’ decision-making in the middle of the night and be continually tested, reviewed and monitored to ensure that the tool was safe as well as effective.
“The key thing was about actually empowering the clinicians to take charge of the clinical outcomes that their patient groups see.”
- Kam Kalari, Associate director for clinical pathways
By simplifying and standardising, RFL have worked together to make wide-reaching changes in order to reduce unwarranted variation in care delivery. Getting it right first time was another priority - to be sure that the care being provided to more vulnerable babies remains safe. They are now consistently delivering high quality care, resulting in improved outcomes for families.
Through the CPG, admissions of term babies into the neonatal unit have reduced from about 13 percent to six percent - a seven percent improvement that has been maintained.
The team estimate that this means that over 350 more families each year can stay together from birth, instead of their baby being admitted to the neonatal intensive care unit*.
Being able to communicate directly with the team, parents were able to directly share, in their own words, the emotional toll of neonatal admission. This helped reinforce the value and the reason for such a large-scale project.
Collaboration was essential. Shanthi highlights that “everyone was integral to the success of this initiative. Co-production with staff and families was crucial in developing this pathway. Fathers often report feeling anxious but forgotten during childbirth, so it was important that the change team included a father’s voice.”
Continually listening to feedback from staff and families helps the team make improvements in realtime, and the team continually work with their community midwife, GP and commissioning colleagues to keep them aware of changes and ensure truly joined-up working.
The shared voice of Royal Free London clinicians and care team
members - as well as families - was integral to success
They monitor emergency department attendances and re-admissions as a measure of how the team are providing holistic care, appropriately addressing parents’ anxieties and ensuring that babies are not presenting with feeding concerns, weight loss or jaundice when going home. Midwife Rose Villar adds “happily, these rates have remained static meaning that we are managing these families well on the post-natal ward and they are being discharged safely home.”
By ensuring all of the workflows across the CPG are digitised in the Trust’s electronic health record (EHR), Cerner Millennium®, they can ensure that care and pathway redesign is underpinned by a single source of truth. Care teams are able to access the right information throughout the patient journey and new dedicated digital workflows support optimal care as designed by the CPG – to help provide the best care possible.
Along with the real-time impact on immediate safety, it also ensures that information is recorded to inform future encounters of both mum and baby.
On the wider CPG programme, Dr Chris Streather, RFL group chief medical officer, said “we will be looking at 44 pathways in the first three years and we think that we will deliver savings of approximately half a million pounds on each through actually improving the patient experience and removing waste. That’s £20million that we can spend on our patients.”
The CPG is seeing real sustained improvements with the project, leading to a place on the Health Service Journal (HSJ) Patient Safety Award shortlist, and NHS Improvement citing it as an example of best practice from which other organisations can learn†.
Most importantly, however, it is patients who are seeing the real difference.
“It’s restored my trust. I think this new approach will also have other benefits like reducing incidents of post-natal depression.”
- Katerina Christodoulou, Patient at RFL
More families are staying together after birth than before,
thanks to the work of RFL’s clinical practice groups
About clinical practice groups:
In partnership with leading US health system, Intermountain Healthcare, RFL have created clinical practice groups, or ‘CPGs’, to review current practice and performance in several key clinical areas. They aim to make changes to improve care quality and efficiency by reducing unwarranted variation in healthcare delivery.
Over 400 clinicians have been involved in the CPG programme at RFL, and real value is being delivered by co-creating clinically embedded pathways built around their patients, of which ‘keeping mothers and babies together’ is one. In partnership with Cerner, these pathways that these CPGs oversee have now been digitised in their Millennium EHR.
*taken from RFL’s 2019 HSJ Patient Safety Award submission
†NHS Improvement, 2019. https://improvement.nhs.uk/resources/keeping-mothers-and-babies-together-clinical-pathway