Maternal and

Neonatal Health
Improving the early recognition and management of
Safety Collaborative deterioration of either mother or baby during early
labour & early post partum period.
To reduce the number of term admissions to neonatal care for suspected sepsis by 25% in a six month
period
Methodology Driver diagram Tests of Change
In order to achieve this aim.. We need to ensure... Which requires... Ideas to ensure this happens
During a drop in use of the RAG rating tool a
In order to reduce admissions we reviewed the The development of a collaborative
approach to the training and
Neonatal and Maternity Educators to
collaboratively develop and provide
PDSA cycle was performed and it was noted
provision of staff

that the amount of information was too great

training for new staff

current newborn pathway and collaboratively To improve the safety and

Adopt a collaborative working
approach towards identifying ,
planning and delivering care to
Implementation of specialist support Implementation of ‘Red bay’
'at risk' babies

designed a risk rating tool to improve effective outcomes of maternal and

neonatal care by reducing
inwarrented variation and
Learn from and design reliable Implementation of RAG rating system
as a reference guide, so the identification was
pathways of care

feeding and thermoregulation: provide a high quality

healthcare experience for
all women, babies and
Develop safe and highly
reliable systems, processes Monitor effectiveness and develop
strategies for improvement
Regular audits and family satisfaction
streamlines and the bulk information was
and pathways of care

placed in the notes for reference. In addition

families across England by
2020
Build capability to improve both the
To reduce the amount of

The information was then placed on
term admissions (>37/40)
to neonatal care for
suspected sespis* by 25%
a ‘hard stop’ was placed onto the Euroking so
culture and the learning system Review results of safety culture
Create a culture of safety and survey and develop strategies to
continuous improvement create an imbedded improvement
Understand the culture and learning

the cot of every baby to share learning in a 6 month period.

*In reciept of antibiotics Learn effectively from episodes of

Identify and create MatNeo datix
the woman was unable to be discharged until
handlers

and care plans with the infants family Learn from excellence and
incidents
avoidable harm
the RAG rating was performed and
Learn effectively from examples of
high quality care and excellence
Offer, review and act on patient and
staff feedback at regular intervals
documented

What’s next?
Utilising audit tools
such as ATAIN and
the staff safety
culture survey has
enabled us to capture
improvement in both
qualitative and Following review and success of the implementation of
quantitative data. the RAG rating the next step is the creation of a neonatal
flow chart for consistent assessment and treatment of ‘at
risk’ infants. This is currently in progress with an aim to
launch by summer 2019.

The bigger picture

The implementation of QI culture into the daily running of the service has improved staff engagement and project support
as well as created a shared vision and meaningful collaboration between Maternity and Neonatal services with a joint aim
to continue to improve the outcomes for Women and babies.
 Tell us your story in a nutshell
In no more than 100 words, roughly equal to the text that will fit in this box. Tell us what you have
achieved with your quality improvement work.

Not everyone is familiar with driver diagrams, control charts and PDSA cycles. So to make your story
as accessible as possible, use this space to tell us very simply:

What you have achieved

What you and your team have gained from the experience
What this means for staff, service users and carers
What is next for you and the team

Any additional team or project photos?

Paste them into a slide and we will share them with your project story!

Please return your completed poster to elft.qi@nhs.net