Q Exchange
Co-designing maternity investigations systems using a Human Factors approach
- Winning idea
- 2024
Meet the team
Also:
- - Dr Al Ross: Associate Professor in Human Factors, Staffordshire University.
- - Sarahjane Jones: Professor of Healthcare Safety and Performance and Associate Dean for Research and Innovation, Staffordshire University.
What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?
Despite improvements in mortality, systemic concerns continue to be noted in maternity services in the UK and worldwide. Recent independent maternity reviews indicate that, despite the introduction of PSIRF, local systems and processes for responding to maternity safety incidents remain inconsistent (e.g. cursory, not multidisciplinary and failing to identify underlying systemic failings) and are rarely subject to interdisciplinary efforts to support improvement efforts.
Human Factors & Ergonomics (HFE) takes a systems approach to improvement and applies tools, methods and techniques to design optimal systems for users’ capabilities to enhance organisational outcomes. To our knowledge maternity investigation procedures, processes and models have not been subject to a systematic HFE assessment. This can add key value across the country in improving these vital management systems so that they are designed for users and clients alike.
What does your project aim to achieve?
This project aims to collaborate with local partners to co-design local NHS trusts governance practices in response to patient safety incidents using a Human Factors approach. This will enable the project team to produce a guide that could be deployed and provide NHS trusts with an evidence-based approach to improve local responses to patient safety incidents. It is anticipated that improvement in local governance systems and processes will result in a more positive learning culture with a view to reducing avoidable harm.
Objectives
· Collaborate with local and national partners to appraise and co-design local NHS trusts governance practices and responses to patient safety incidents by collaborating with staff on a task, job and organisational analysis
· Co-design with users a guide for optimal systems that can be deployed to support maternity services to improve local responses to patient safety incidents.
How will the project be delivered?
A team of HFE and independent maternity investigator experts will conduct an innovative design review of NHS Trust governance systems and processes using key principles of Organisational Ergonomics. We will work with system users to understand if current practices systematically examine safety incidents, identify systemic concerns and share learning appropriately. We will apply evidence-based Ergonomic principles and the review findings will then be synthesised in a guide to support maternity services to practically deploy and operationalise a system-based approach to learning from patient safety incidents. The project team have vast experience in delivery of health services research and evaluation, delivering value for money and mitigating project risks. Clinical partners will be fully involved to improve the service to the ultimate benefit for patients and families . We believe our key output delivers a ‘pathway to impact’ in that it can be deployed by governance teams across and possibly beyond the UK.
How is your project going to share learning?
We have close links, again through formal advisory and committee roles, with NHS England, HSSIB and NHS Education for Scotland including access to an online hub for promoting and hosting resources to affect policy, practice, education and research in organisational performance and staff wellbeing. Locally we will host engagement events with stakeholders; the university works in partnership with a vast number of NHS trusts.
- At national level we will prepare briefing documents for NHS England
- We have clear routes to peer-reviewed publication; we envisage publishing results in journals such as the BMJ Quality and Safety which we have published in previously.
- We regularly attend (invited keynote speakers) international patient safety and Human Factors conferences where we will present our findings
- We have partners and networks across the UK and in the Middle East, Far East and Australia where we can present outcomes at education and research meetings
How you can contribute
- We invite all members of the Q community to share your expertise, insight and critical friendship with us on this journey.
- Please help us to develop and refine our project idea by sharing it within your networks and with interested colleagues to comment and contribute.
- We are especially pleased to discuss partnership with those working in any aspects of maternity service governance and oversight, safety incident reporting and investigations, team and organisational learning.
Plan timeline
| 2 Sep 2024 | Establish a Human Factors and maternity governance stakeholder community |
|---|---|
| 2 Sep 2024 | Initiation Meeting |
| 4 Nov 2024 | Workshops: Human Factors appraisal of local safety review systems |
| 10 Feb 2025 | Mid-Project Meeting |
| 10 Feb 2025 | Workshops: Co-design optimal learning systems to support maternity reviews |
| 7 Apr 2025 | Launch: Co-designed user guide |
| 9 Jun 2025 | Focus groups: feasibility and acceptability of implementing the user guide |
| 4 Aug 2025 | Workshop: Dissemination and impact |
| 31 Aug 2025 | Project Closure |
Comments
Dr Tom McEwan 8 Jul 2024
Amazing to see this project receive funding- this has huge potential to impact positively in this space of maternity investigations and help move the discourse from blame and shame to a systems focussed approach that leads to impactful learning- looking forward to support in any way I can.
Lorraine Cardill 6 Jul 2024
This is fantastic and well done to the team!! I would really like to be involved in any stakeholder groups to support from a maternity experience perspective and utilise my Human Factor knowledge.
Lizzie Crisp 6 Jul 2024
Thank you for your supportive comment Lorraine.
We are delighted that this project has been funded and would welcome your expertise!
Could you possibly send me an email to elizabeth.crisp@staffs.ac.uk and we can arrange a Teams meeting to discuss the project and participation in the stakeholder community.
Best wishes,
Lizzie
Joanna Garrett 5 Jul 2024
Really pleased to see this project succeeded in getting funding in this years Q exchange. I'm part of the Maternity and Neonatal Independent Senior Advocate pilot to support families where they have questions or concerns after an adverse outcome. The issues we see are often complex and across systems and the investigation solutions are not always representative of that.
Would be very happy to be part of your community group.
Lizzie Crisp 5 Jul 2024
Thank you for your interest in supporting this project Joanna
We are delighted that this project has been funded.
Could you possibly send me an email to elizabeth.crisp@staffs.ac.uk and we can arrange a Teams meeting to discuss the project and participation in the stakeholder community.
Best wishes,
Lizzie
Constantinos Regas 9 Jun 2024
This is a very interesting project.
Is it worth linking in with the PSIRF prompt cards team for the sharing of learning?
best wishes
Constantinos
Lizzie Crisp 10 Jun 2024
Thank you Constantinos, we agree it is a much needed piece of work. We of course would welcome collaboration and sharing of learning with any of our Q colleagues should we be successful.
Zoe Munson 20 Mar 2024
Whilst working for the Maternity and Newborn Safety Investigation programme (MNSI) (formally HSIB), I have seen the value of doing system focused investigations for families, trusts and the wider NHS. This proposal sounds well timed and over due; Will look forward to seeing the impact of this proposal.
Cal Latham 20 Mar 2024
Overall, your proposal demonstrates a clear understanding of the challenges in maternity investigation procedures and proposes a well-structured approach to address them. Your emphasis on collaboration and evidence based practices indicates a strong commitment to driving meaningful change in healthcare systems.
In addition, your anticipation that improvements in governance systems will foster a more positive learning culture within the NHS is both insightful and forward-thinking. By incorporating a multi-disciplinary approach will ensure comprehensive analysis, innovative solutions, and effective implementation strategies to enhance maternity investigation procedures and promote patient safety across NHS Trusts.
Lizzie Crisp 20 Mar 2024
Thank you for your comments and feedback Cal! it is great to see the enthusiasm and interest that this proposal is generating!
Best wishes,
Lizzie
Charlotte Williamson 20 Mar 2024
This is such a timely and worthwhile project addressing much a needed gap in maternity systems. The proposal offers a real opportunity for learning and improvement in maternity investigation systems, and has the potential for widespread impact. This is an innovative and exciting opportunity to apply HFE to the learning system itself and I’d be excited to support this project where possible.
Elizabeth Crisp 20 Mar 2024
Thank you for your feedback and support Charlotte. We agree it is an incredibly worthwhile and timely project with a direct path to impact. We welcome the support and engagement of all stakeholders and Q community members!
Best wishes,
Lizzie
Al 20 Mar 2024
Thanks Charlotte
We do think HF-based co-design can help learning systems meet their aims; it'd be great to take this forward.. !
Al
Yetunde Ataiyero 19 Mar 2024
Very timely and much needed study with a significant potential at reducing the systemic challenges and widening inequalities for those accessing maternity services. The proposed co-designing approach will be particularly useful in engaging service users from the underrepresented communities. Very best wishes with the proposal and happy to support any way I can!
Lizzie Crisp 19 Mar 2024
Thank you Yetunde for your feedback. I absolutely agree we need to examine the widening inequalities as part of the appraisal process and indeed address these in the codesign of local safety systems. We will be looking to expand our stakeholder group and would welcome your expertise in amplifying the voices of both staff and service users from underrepresented communities in the codesign process.
Best wishes
Lizzie
Tracy 13 Mar 2024
This project sounds really interesting and creating a guide for operational approaches to incidents would provide consistency in all areas. This study would certainly be beneficial to patient safety with all the concerns around maternity and can see the need for it. The collaborative working with trusts sound like a great opportunity, I am excited to see how the project develops and the results. I am willing to support if required.
Lizzie Crisp 13 Mar 2024
Thank you Tracy
We agree working collaboratively with trusts is an exciting opportunity to work towards improving local responses to maternity safety incidents.
Thank you for your support!
Best wishes, Lizzie
Paul Anthony Broad 11 Mar 2024
Thank you for sharing Lizzie.
In light of some of the recent media coverage surrounding maternity care services across the UK, your line of enquiry (Proposal) could not have come at a more apt time. I wish you every success with your project.
Lizzie Crisp 12 Mar 2024
Thank you for your comment and feedback Paul. We agree that this proposal is timely and much needed. We look forward to sharing progress if we are successful.
Best wishes,
Lizzie
Al Ross 12 Mar 2024
Thanks Paul
I think HF is gaining a little traction in trying to extract useful learning from events. But ironically there is little (no?) evidence of HF being used to improve learning systems themselves. These are complex, sociotechnical, and involve IT, training, tools and techniques; they have time pressures and organizational cultures and imperatives; and they have multiple sometimes misaligned goals.
The project will seek to apply HF in this way which I feel is truly innovative (Lizzie's 'lightbulb' moment btw!), and through co-design with users and clients 'make it easy to do the right thing'.
Cheers Al
Tom McEwan 8 Mar 2024
Dear Lizzie, Al and Paul,
This is an incredibly exciting a long overdue project. Systems thinking in maternity safety reviews is often lacking, absent in reports, as well as the influence of workforce culture. My additional thought would be to consider expanding this to perinatal given the close alignment between maternity and neonatal care as incidents often straddle these disciplines and the associated clinicians. Happy to help in any way I can.
Tom.
Dr. Al Ross 8 Mar 2024
Thanks Tom
Very insightful comment and something to bear in mind; great to continue the conversation...
Al
Lizzie Crisp 8 Mar 2024
Thank you Tom for your comments and feedback. We would be delighted to work with you on this valuable and much needed project.
Best wishes, Lizzie
Natasha Green 7 Mar 2024
Maternity services' readiness to acknowledge and address human errors is a crucial indicator of their commitment to enhance safety and quality of care. Outlining the incident review process, disseminating findings, and establishing procedures to apply the lessons learned to future maternity care is fundamental. I look forward to the progress and results of this study.
Lizzie Crisp 8 Mar 2024
Thank you for your comments and support Natasha. We agree that this initiative is long overdue and much needed, and it has the potential to assist trusts in raising the standard of care in a field of healthcare delivery that is becoming more complex and demanding.
Best wishes, Lizzie
Paul Bowie 7 Mar 2024
Great, thanks for your support Natasha, best wishes
Hazel A Smith 6 Mar 2024
Due to changes in patient demographics and conditions plus advances in clinical research we are seeing risks increase for patients. As mortality decreases, morbidities increase. Time and time again we have had local and national reviews and nothing appears to improve. Healthcare professionals so often focus on guidelines on clinical management and do not include wider but important factors, such as systems approach. I think this study design is well overdue and excited to see the findings.
Lizzir Crisp 12 Mar 2024
Thank you for your comments and feedback Hazel. We look forward to working with you should this proposal be successful.
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thank you for your feedback Hazel. We agree it is a much needed and overdue piece of work and has the potential to help trusts improve quality of care in an increasingly demanding and complex area of healthcare provision. We would welcome any further thoughts you have and would welcome your support.
Lizzie, Al and Paul
Mark Chester 6 Mar 2024
This looks a really good idea. I have worked as an obstetrician for 15 years, and always had an interest in human factors. If there is anyway I can support or help, please feel free to get in touch.
Lizzie Crisp 5 Jul 2024
Thank you for your interest in supporting this project
We are delighted that this project has been funded.
Could you possibly send me an email to elizabeth.crisp@staffs.ac.uk and we can arrange a Teams meeting to discuss the project and participation in the stakeholder community.
Best wishes,
Lizzie
Lizzie Crisp 12 Mar 2024
Thank you for your comments and engagement Mark. It is great to see comments on here from human factors experts, midwives, obstetricians, neonatologists and anaesthetists. As Paul has said we will be looking to grow our stakeholder engagement group and would welcome your input.
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thank you Mark for your comments. We have had lots of positive comments on social media from the Human Factors community including a trustee of the CHFG. It is wonderful to hear from an obstetrician with an interest in human factors. We are looking to grow our stakeholder engagement group and would welcome your participation and engagement.
Lizzie, Al and Paul
Al Ross 8 Mar 2024
Thanks Mark
It's vital this is multi- and inter-professional so your comment is timely and much appreciated. Al
Amanda Wilford 6 Mar 2024
Hello Lizzie and Paul,
I think this is a great project - my thoughts are that one of the reasons that organisations do not understand how to look at incidents in this manner is that they do not know how to do a local needs analysis - could part of the project provide a simple way to do this? Thinking a simple tool/flowchart etc .
I agree with the earlier comments that this important work needs to be undertaken and potentially findings could influence other care groups.
If i can support in anyway, I would like to.
Lizzie Crisp 12 Mar 2024
Thank you for your feedback and support Mandy. We would welcome your support and engagement with the project should it be successful.
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thank you for sharing your thoughts Amanda. You raise a really good point about it’s potential in other care areas. . We are looking to grow our stakeholder engagement group and would welcome your support throughout this project if we are successful.
Lizzie, Al and Paul
Al Ross 8 Mar 2024
Thanks Mandy
As you know I am generally of the notion that translational simulation is a useful tool for system development and design; we have a PhD student at HSSIB studying the utility of simulation for optimizing learning from events- so we'll bear you in mind!
Al
Joe Natalello 5 Mar 2024
The potential impact of your project extends beyond immediate improvements in maternity services and by fostering interdisciplinary collaboration and addressing underlying systemic failings, it has the potential to enhance organisational outcomes on a broader scale.
This strategic perspective adds significant value to the overarching goal of improving management systems for the benefit of both users and clients across the country. Additionally, your project's holistic approach positions it as a valuable initiative with the potential to contribute substantially to the improvement of maternity services.
Lizzie Crisp 12 Mar 2024
Thank you for your support Joe!
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thanks Joseph, you have as others have identified the pathway to impact. Thank you for sharing your thoughts and insights.
Lizzie, Al and Paul
Vanda Carter 5 Mar 2024
I think this is a really exciting, topical and interesting proposal. The proposal is refreshingly multidisciplinary / interdisciplinary, learning and solution focused, using a systems approach to improve local responses to patient safety incidents.
Understanding the why who what when and how through expert facilitation, engaging, listening and learning with clinicians/stakeholders themselves will help to fully understand barriers and enablers, inform and deliver much needed solutions and improvements culminating with the proposed output ‘pathway to impact’. I offer my support and am confident that our regional teams will be very excited and positive about this work and want to be part of it.
Lizzie Crisp 12 Mar 2024
Thank you for your support and comments Vanda!
As Paul has already mentioned we would be very excited to collaborate with you as a member of the Q community, researcher and clinician!
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thank you for your support Vanda! it is great to have the support of Q members. We are equally excited and agree that the proposed output is a pathway to impact. We would be delighted to collaborate with you.
Lizzie, Al and Paul
Lauren Philp-von Woyna 1 Mar 2024
This initiative is timely and very much needed. It identifies a gap that has potential to address and respond to maternity safety concerns and incidents in a way that can facilitate understanding and learning locally and more broadly. With ongoing safety and culture concerns across maternity services in the UK, an approach which integrates principles of organisational ergonomics in working with trusts to improve local response to incidents is advantageous. I'd like to support this project where possible.
Lizzie Crisp 12 Mar 2024
Thanks Lauren
We would welcome your support and engagement as a fellow midwife with an interest in human factors!
Best wishes,
Lizzie
Paul Bowie 8 Mar 2024
Thank you Lauren. We are pleased you agree that this proposal is timely and very much needed. We are looking to grow our stakeholder engagement group and would welcome your participation and engagement.
Lizzie, Al and Paul
Al Ross 8 Mar 2024
Thanks Lauren
Yes HFE principles are becoming a little more evident in data extraction i.e. when attempting to learn from adverse events, but have seldom if ever been used to help providers design optimal reporting and learning systems themselves. Al.
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