IDEAS & RESOURCES FOR IMPROVING INDUCTION OF LABOUR PRACTICE

• Jacqueline Laurie, Consultant obstetrician and gynaecologist, Scottish Quality and Patient Safety Fellow

If you are intending to use any of these materials, please can you acknowledge the Trust who have developed the original by stating ‘This work was originally undertaken by XXXX Trust/Health Board’ 

IOL can be considered a complex system meaning that robust quality improvement science is the best approach for seeing demonstrable improvement through change. The perfect solution within one department is rarely directly transferable and it is vital to consider your own context as unique to your department to maximise positive change.

Step 1 – create the conditions for change

Get on the shop floor and speak to the staff and patients about IOL. Do the staff and patients think that the system needs to improve? Are they willing to change to make an improvement possible? Is there a potential to improve the system? Are there obvious barriers that mean an improvement project is likely to fail before it starts? 

Next, speak to the managers. Does this improvement work align with board priorities? Is there an appetite for investment in this area of the service?

If the answer to any of these questions is no, address it before moving to the next step. It is possible to build will and influence decision makers so don’t give up. Use data to show how long the induction process takes in your unit. Use patient stories to highlight the value in outpatient induction. Use bed occupancy rates to show the board how an investment may result in long term gain. You need to learn how to speak all the stakeholders’ languages to use your influence.

Step 2 – Identify the problem

Which element of quality in the induction process requires improvement? Consider each element of quality – safe, timely, effective, efficient, person centred, equitable. It is likely that your IOL project will impact in most of these areas but involve all stakeholders to identify the project’s focus. Explore all the sources of intelligence to guide you – complaints, adverse incident reviews, patient feedback, audit data. Now develop your team which will be dependent on your focus. In addition to an obstetrician and a midwife, other roles that may be required are lay representatives, pharmacists, digital midwives, managers. Build the team to best fit with your focus.

Step 3 – Understand your system

Start to develop the process map for how the induction process currently works in your system. This will take many rounds to produce something that is as close as possible to the reality.

First, get an improvement advisor to sit with the member of the team who best understands the system and ask them to talk through the process from booking to delivery and produce a high-level process map. Then take that high level map to the team meeting along with post-it notes and ask people to add in any steps that have been missed. Then take this process map onto the shop floor and ask as many staff as possible to make comments and changes to produce the final draft. This tool will be the most valuable document in your folder. First highlight non-value adding steps. These are often your “quick wins”. Next identify areas where there is variation. This variation may be in the booking process, the induction agent used, the member of staff delivering the induction agent. Variation in the system introduces confusion and the simplest process possible will help to improve all areas of quality discussed above. This map will also help to identify activity around the constraints in the system. In the case of IOL, the main constraint is usually access to labour ward so the map may need expanded around this area to allow it to be studied in greater detail. 

Step 4 – Develop your change theory

Within the team, produce a SMART (Specific, Measurable, Achievable, Relevant and Time bound). It should align to the focus identified in step 1. For example, is the focus to be delay? Patient experience? Bed occupancy?

Produce a driver diagram as a visual representation of your improvement plan. Figure 1 shows an example of one produced by Birmingham Women’s and Children’s NHS Foundation Trust as part of their QI project. Your primary drivers should be big topics or areas that require work to achieve the aim. Your secondary drivers are the factors that need to be in place to influence the primary driver. Finally, the change ideas are the things that can be done differently which will impact on the drivers and therefore the outcome. These are the changes that you are going to test in step 5. It is vital to involve the staff delivering the induction service in the development of the change ideas. Staff who feel empowered to develop and test changes to their own practice are far more likely to make meaningful improvement.

Step 5- Formulate a measurement framework. Your improvement advisor can help with this. Most projects will involve at least 5 measures. Don’t forget qualitative measures. When working on IOL, the opinions of the service users is going to be key to showing improvement. 

Outcome measure – relates directly to your aim.

Process measures – relate to the areas in the process that you are targeting for change. For example, rate of out-patient induction, number of women receiving a cervical ripening balloon as the first line induction intervention. These relate to the primary and secondary drivers in your driver diagram. 

Balancing measures – relate to unintended impacts of your change. An example of this is the number of patients who receive terbutaline, or the rate of cord prolapse.

Gather “just enough” data to learn and collect it “little and often”. Present the data on run charts or control charts to demonstrate change over time. When you make a change, annotate your charts to show, at a quick glance, the impact of the change. 

Step 5 – Test of change

From the driver diagram, select your first change to test. A useful tool at this point is an impact/effort matrix. The easy changes with maximum impact are what are known as “quick wins”. If it is not clear which change to start with, discuss it with the staff who developed the change ideas. Where would they like to start?

Use PDSA cycles to test your change idea. 

· Plan the change you are going to make. Try to predict what you think will be the outcome of the test. 

· Do the change. Start small – try it with one patient on one day and gradually build from there. 

· Study the change -what happened?

· Act – make the changes necessary to your change idea to improve its impact. Keep building on success and learning from failure to maximise the impact of the change. 

Continually refer to the 3 key questions in the model for improvement:

• What are we trying to accomplish?

• How will we know if a change is an improvement?

• What changes can we make that will result in an improvement?

When you are ready, implement the change in the area in which you tested it. Continue to study its effect using outcome and process measures. Be ready to make adjustments so as to ensure that the improvement is sustained. After this, you may feel ready to spread the word of your success and share your ideas across boards, nationally or even internationally. 

TOP TIPS!

• Simplify the system - one way in, one way out, one team managing the process
• Spend enough time understanding the system
• Don't fall into the trap of thinking that you have the perfect solution - listen before trying to be listened to
• Make sure change ideas come from the ground up, not the other way round
• Don't let seeking permission to make change stop you - it is worth it!