3 centres collaboration

Guideline Implementation

Contents:

The guidelines outlining the best available evidence for care of Women with Uncomplicated Pregnancy were completed in October 2001.

The challenge then was to apply this evidence across maternity care services in Victoria. The evidence for guideline implementation and practice change recommends properly resourced, multifaceted strategies tailored to local issues and practice and cautions against simplistic strategies, inadequate timeframes and opportunism.

How did we implement the 3centres guidelines?

1. Each tertiary maternity service developed its own plan, and tailored the strategies to the organisational context.

Mercy Hospital for Women and Monash Medical Centre agreed to group the Guidelines into four sets and tackle one set at a time.

Multidisciplinary site teams were convened and they began to meet and identify the barriers and bridges to implementation. A project midwife assisted this process by interviewing across section of staff. She worked with site teams on process redesign, mapping of patient journeys and designing staff supports.

2. The steering group worked on issues such as changing the legislative requirements around midwives offering HIV screening to pregnant women.

3. Shared Care Affiliates, consumers, allied projects, training providers and professional colleges were engaged. A one year project plan incorporating facets and insights from the literature on effective guideline implementation was developed and ran from June 2002-June 2003

Over 1200 Shared Care Affiliates were surveyed for their knowledge of the Guidelines, evidence based practice and for their education needs. An education intervention was then designed specifically for them.  This education program utilised adult education principles and to aimed to help participants:

  • Understand the implications of the Guidelines for content and timing of visits
  • Implement the Guidelines
  • Discuss tests and investigations using effective, woman-centred communication skills
  • Train their colleagues

12 interactive and multidisciplinary facilitator training workshops and a special workshop for community providers was provided to address:

  • Clinical Content: What the guidelines say or imply
  • Communication Skills: How to discuss and offer tests and woman-centred care to women in real world settings
  • Culture(s): What are the influential philosophies and values that govern why antenatal care ‘happens’ the way it does? What is the cultural basis of my practice? Common barriers such as “lack of time” and “women don’t want this role” to be discussed and challenged.

The workshops were successful at disseminating the 3Centres Guidelines throughout Victoria, impacting well over 800 health professionals. A total of 218 midwives, clinical educators, GPs and obstetricians attended the 12 workshops. 48% (105) trained as facilitators. Another 400 health professionals were trained in 2003. A total of 230 GPs and Midwives attended the special Melbourne SMCA workshop.

Participants considered the facilitator training workshops useful and 92% said they would recommend it to colleagues. The SMCA workshop, planned on the basis of a needs analysis, received a high ranking with 87% rating it ‘helpful’ or ‘very helpful’.

4. A multifaceted program was designed to support change through the Victorian maternity care system in collaboration with other maternity care projects.  These include:

  • Sharing Shared Care Project to develop Process Guidelines for Shared Care Affiliates [2001-2002]
  • The Victorian Maternity Performance Indicators Project [2002-2003]
  • Various projects to develop web and written evidence based consumer information incorporating the Guidelines [2001-2003]
  • Statewide Dissemination and Training Project for the 3Centres Consensus Guidelines on Antenatal Care[2003]
  • Development of a Victorian Handheld pregnancy record [2004-2006], and incorporating the "guide to tests and investigations in pregnancy [2006-2009]
  • Having a Baby in Victoria website
  • Statewide Pregnancy training package

Weaving a Web Poster (PDF)

5. An audit of guideline implementation was conducted (2005) and results feedback to the organizations (2007)

An audit to assess practice consistency (in caring for low risk pregnant women) with guideline recommendations was conducted pre guideline development, 6 months post implementation and 2 years post implementation (Pre – September 1, 2001, Post 1 – December 1, 2003, Post 2 – July 1, 2005).

75 consecutive records of completed pregnancies meeting the inclusion criteria at dates to satisfy the pre implementation and post implementation criteria were selected.

The 3centres outcomes audited were:

  • Is there evidence that a discussion took place about models of care?
  • Are there any risk factors present? 
  • What was the date of the first visit?
  • How many visits did this woman have?
  • What was the date of delivery?
  • Was the woman’s weight recorded?
  • Was the woman’s height recorded?
  • Was BMI calculated?
  • Is BMI between 18 and 35?
  • If BMI <18 or >35 is there evidence of management plans?
  • HIV – evidence of pre-test discussion?
  • Was HIV test performed?
  • HEP B – evidence of discussion?
  • Was Hep B test performed?
  • Hep C – evidence of discussion?
  • Hep C – evidence of risk assessment?
    • History of injecting drugs?
    • Partner past or present who injected drugs
    • A tattoo or piercing
    • Been in prison
    • Received blood which later tested positive for Hep C
    • Been on long term haemodialysis
    • Received an organ transplant before July 1992
  • Is the woman at high or low risk for Hep C? 
  • Is a result for Hep C test recorded? 
  • Evidence of discussion about urinalysis at booking?
  • Asymptomatic Bacteriuria – evidence of a discussion?
  • Was there early screening for ABS?
  • Was there evidence of risk screening for renal disease?
  • Was there evidence of risk screening for UTIs?
  • If evidence of renal disease or UTIs, was MSU collected?
  • Which test was performed-dipstick or microscopy and culture?
  • If dipstick positive for blood, protein, nitrites and leukocyte esterase was a sample sent for microscopy and culture?
  • If GP collected MSU, were results sent to hospital by referring GP?
  • At any visit was the woman hypertensive? BP >140/90
  • If the women was hypertensive, was urinalysis performed at any of these visits?
  • Is there evidence of discussion about prenatal screening?
  • Was a prenatal screening test performed?
  • If a prenatal screening test was performed, which was it?
  • Is there evidence of a discussion about diabetes screening?
  • Was a diabetes test performed?
  • Was the test OGCT, OGTT or both?
  • Is there evidence of discussion about GBS?
  • Was a GBS test performed?
  • Was the GBS test positive?
  • If GBS positive, was the mother or baby treated?

Feedback of audit results was offered to the tertiary maternity services in 2007. These sessions included a group discussion and analysis of barriers to guideline implementation, which were used to develop targetted "enhanced implementation" of selected guidelines. This process is adapted from recommendations from the National Institute of Clinical Studies (NICS).

What did we learn?

  • Influencing and changing clinical practice is difficult
  • Communicating information and providing education alone is unlikely to change practice. There are complex social dynamics associated with change and multifaceted processes are needed.
  • Strong leadership and ongoing commitment is critical and needs to be sustained by ongoing commitment to supporting relationships and actively involving people in the process
  • Multidisciplinary training is important in promoting team based care
  • A paradigm shift was required to develop more interactive training models
  • Incentives (such as professional development points) are important in promoting participation in professional education
  • Workshop attendance increased participants' knowledge and uptake of the 3Centres Guidelines in many areas of antenatal practice in the 4-6 weeks immediately following workshops. The pre and post workshop surveys for both facilitator training and the Shared Maternity Care Affiliate [SMCA] workshops demonstrate many positive shifts in antenatal practice in line with Guideline requirements, including the discussion of certain tests with women.
  • Workshop attendance increased participants' awareness of the barriers to guideline implementation. Before the workshop more people perceived fewer barriers for fewer guidelines and expected implementation to be very straightforward. Post workshop, the most commonly cited barriers to implementation were tradition, lack of time, lack of knowledge, lack of confidence and opposition or lack of support from colleagues or management.
  • Guidelines on HIV screening, number of visits, Down syndrome screening and Smoking Cessation were considered the hardest to implement. These Guidelines and barriers required follow up with targeted strategies and supports.
  • Documentation may not reflect actual care given which makes accurate auditing difficult

    What were the major challenges?

    • High turnover of key staff
    • Time pressures
    • Lack of resources
    • Lack of multidisciplinary training opportunities

      Reflections from the project team

      • I feel overwhelmed most days.
      • I have carried a very big load for this hospital without a lot of support. We have meetings and try to engage people but it has been difficult to put so much work for little reward and little to show for it. 
      • This big project has been carried without medical support.
      • The preliminary work is done but it is far from implemented in process and culture. Planning is easy. Culture is hard.
      • There a lot of little wrinkles that we haven’t sorted out.
      • It is so fragile it only works 50% of the shifts. It doesn’t function when we are stretched…this is directly due to staffing. It is not systematised yet. We haven’t grown all the necessary processes.
      • There has been a lot of brushing over of issues …we need a daily reminder about what we should be doing and so residents and registrars know what to do.
      • Documentation systems have not kept apace with staffing changes eg developing a pregnancy record (this was largely due to the time it took to consult with polarised groups)
      • We need a better education strategy. You can’t implement anything if people are not confident and informed about it.
      • I have found lack of leadership and ownership really difficult. I find it extremely difficult to have people at the head of the ship not owning them and saying ”Right this is what we are doing.” I go to site meetings and know that we won’t get anywhere because the problems are bigger than the seniority of the people there.
      • If it falls over it won’t be because the medical staff sabotaged. It will be because we all got too tired.