Implementing recommendations arising from confidential enquiries into maternal deaths

Abstract

Implementing recommendations is a complex process involving all levels of health care. Effecting change in the health system can be broadly divided into four areas: policy, administration, clinical practice and training. Changes at the policy level require advocacy by lobby groups, as these changes are mainly political in nature. Changes at administrative level require a diversion of resources, and a clear policy framework must be in place within which the health administrator can work. Changes to clinical practice refer mainly changes in protocols of managing patients. The essential elements to change clinical practice include on-site, face-to-face teaching by a senior clinician; ineffective methods are lectures and memorandums on guidelines for practice posted to clinicians. Training refers to ensuring there are appropriate curricula for healthcare workers. Recommendations should also be phrased in such a way that targets can be established. These targets should be measurable and then be measured.

Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa

“…Change is thought of as a complex process in which different factors act as barriers or facilitators [20]. No single factor is responsible for bringing about change.…”

“…With regard to drivers or change agents, Pattinson and Bergh distinguish between "enablers" and "doers" in the context of implementing recommendations following confidential enquiries into maternal deaths [20]. Applied to perinatal audits, the doers would be the clinicians responsible for service delivery, for implementing the audit system and ensuring that the necessary recommendations to complete the audit cycle are implemented to change practice and improve quality of care.…”

“…giving staff time to perform their audit duties adequately). For change agents to operate successfully, there must be appropriate formal and informal communication channels (with proper information flow) [25], some form of clinical or specialist outreach [26,27] and other networking opportunities throughout the health system [20]. …”

“…Changing one aspect, such as introducing an audit programme, means many other aspects would also change [20]. Conducting audit and giving feedback at morbidity and mortality meetings and other educational and review meetings still does not mean that quality of care will improve automatically.…”

What is needed for taking emergency obstetric and neonatal programmes to scale?

“…Internally owned data may enhance sustainability; however, it is possible that this process ends up placing a burden on individuals at the centre of a programme, from national to institutional level. Mechanisms to enable the system and facilities, not just the passionate individuals and drivers, to support data collection are essential and the assessment and monitoring of a scaleup programme [65].…”