How to be a very safe maternity unit: An ethnographic study

Abstract

Maternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. As in other areas of healthcare, improvement efforts have typically focused either on implementing and evaluating specific interventions, or on identifying the contextual features that may be generative of safety (e.g. structures, processes, behaviour, practices, and values), but the dialogue between these two approaches has remained limited. In this article, we report a positive deviance case study of a high-performing UK maternity unit to examine how it achieved and sustained excellent safety outcomes. Based on 143 h of ethnographic observations in the maternity unit, 12 semi-structured interviews, and two focus groups with staff, we identified six mechanisms that appeared to be important for safety: collective competence; insistence on technical proficiency; monitoring, coordination, and distributed cognition; clearly articulated and constantly reinforced standards of practice, behaviour, and ethics; monitoring multiple sources of intelligence about the unit's state of safety; and a highly intentional approach to safety and improvement. These mechanisms were nurtured and sustained through both a specific intervention (known as the PROMPT programme) and, importantly, the unit's contextual features: intervention and context shaped each other in both direct and indirect ways. The mechanisms were also influenced by the unit's structural conditions, such as staffing levels and physical environment. This study enhances understanding of what makes a maternity unit safe, paving the way for better design of improvement approaches. It also advances the debate on quality and safety improvement by offering a theoretically and empirically grounded analysis of the interplay between interventions and context of implementation.

Finding “What's Wrong With Us”: Antibiotic Prescribing Practice Among Physicians in the United States

“…The data analysis was conducted onsite and as such I had contact with participants throughout the data analysis period (cf. Liberati et al, 2019). Participant feedback was solicited regarding the key themes and codes that were formed during data analysis.…”

Obstetrical safety indicators for preventing hospital harms in low risk births: a scoping review protocol

“…We will identify variables that are relevant and develop a standardised data collection form. 15 Two reviewers will independently carry out data extraction for each included record. Initially, we will independently extract data from five randomly selected, included records and compare the extracted data for consistency.…”

“…14 In the UK, an ethnographic study of a maternity unit with an excellent record for patient safety found that staff partly attributed its success to a maternity dashboard which facilitated audit and feedback. 15 The Better Outcomes Registry & Network (BORN Ontario) developed a dashboard of six key clinical performance indicators to measure data relating to the quality of maternal and newborn patient care in Ontario, Canada. [16][17][18] In a pilot study, a quality improvement project focusing on one of the indicators identified by BORN, led to a welcome and significant reduction in the rate of elective repeat caesarean sections in low risk women at less than 39 weeks' gestation.…”

Obstetrical safety indicators for preventing hospital harms: a scoping review protocol

“…Stage 4: Charting the data We will identify variables that are relevant and develop a standardized data collection form (15). Two reviewers will independently carry out data extraction for each included record.…”

“…The Institute for Healthcare Improvement (IHI) Framework for Safe, Reliable and Effective Care identifies processes of improvement and measurement as a part of the health care learning system (14). In the UK, an ethnographic study of a maternity unit with an excellent record for patient safety found that staff partly attributed its success to a maternity dashboard which facilitated audit and feedback (15). The Better Outcomes Registry & Network (BORN Ontario) developed a dashboard of six key clinical performance indicators to measure data relating to the quality of maternal and newborn patient care in Ontario, Canada (16)(17)(18).…”