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The response to a crisis experienced in the maternity unit at Waitakere Hospital, New Zealand resulted in profound improvements in care
Waitakere Hospital in urban West Auckland has a busy maternity unit. Most of our mothers receive care from independent midwives working within the hospital’s birthing facilities. Complications during labour are referred to the duty obstetrician. Natural anxiety about coping with emergencies during labour and childbirth is exacerbated by the unit’s isolation from other acute services. In 2001 multiprofessional dissatisfaction provoked a breakdown in relationships between obstetricians and midwives.
In some aspects of obstetric care we were not alone. Caesarian section rates in New Zealand between 2001 and 2002 increased from 20.8% to 22.1%,1 but when our caesarian section rate hit 27% the sense of crisis was ours. Pofessional relationships fractured in a series of “tipping point” events (box 1). The symptoms of a breakdown rapidly multiplied: nine major patient complaints in 3 months; enquiry into neonatal deaths; an obstetrician suspended for competency review; and independent midwives refusing to attend hospital policy review meetings at which clinicians questioned midwifery practice. The viability of on call rosters was threatened as morale plummeted and staff resigned.
Box 1 A “tipping point” crisis
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The mother had written an eight page birth plan: no drugs, no machines, no medical interventions; childbirth was to be a mystical and rewarding experience. Progress was slow. The midwife encouraged, supported, and coached the mother through a day and night of painful labour. After an hour of pushing, the exhausted mother began to despair. The midwife was concerned about fetal wellbeing and began continuous monitoring of fetal heart rate. The trace was not reassuring. Experience had taught her that calling the obstetrician would lead to immediate caesarean section. After another half hour of pushing, there was a sudden and prolonged deceleration in fetal heart rate. The obstetrician was called and hurried into the room, followed closely by the anaesthetist. He took one look at the fetal heart rate and told the mother she needed an immediate caesarean. Suddenly there was a rush of frantic activity. The mother burst into tears. Her husband became angry. Consent forms were thrust at the mother and she refused to sign. The midwife and obstetrician exchanged angry words. The obstetrician began to push the bed down the corridor towards theatre while the anaesthetist attempted to complete his pre-anaesthetic evaluation. The mother, nearly hysterical with pain and fear, consented to general anaesthesia and surgery. A healthy baby was delivered. Neither mother nor father witnessed the birth of their child.
A way forward with better, safer working practices seemed impossible. It was clear that resolution would only come through a process that focused on interprofessional relationships, however obvious the practical solutions to our problems of poor quality care might seem. A joint letter from 27 independent midwives gave us the opportunity to re-engage, although not before the Minister of Health became embroiled in the dispute. Midwives wrote of serious concerns about their professional autonomy, women’s rights, and poor relationship with obstetricians. A series of meetings exposed the high levels of anxiety, anger and blame on all sides. We responded with a process specifically designed to rebuild trust and focus on common goals.
A “DRAMATIC” INTERVENTION
Known thereafter as the “Big Day Out”, a crucial 1 day workshop led by an outside facilitator was convened, attended by 65 people comprising all the main contributors to obstetric care—obstetricians, anaesthetists, paediatricians, midwives, and consumer advocates. To ensure maximum attendance, clinics and routine operating lists were cancelled and locums provided cover for urgent patient care.
The workshop was unusual. Planned but unscripted, it was based on role play. For most, this was an unfamiliar approach to learning and many were fearful. Participants role played labour room crises, slowing down time to allow exploration of interactions, behaviours, beliefs, and difficulties in communication. At first roles were represented by moving furniture. Gradually people volunteered to play their own roles, then others’ roles. At times the tension was electrifying. Some courageously and openly admitted their learning. An independent midwife role playing an obstetrician declared she had never before realised that obstetricians cared about mother and babies as she did, and believed that obstetricians just wanted to do operations; she now appreciated the stresses obstetricians experienced. The changed behaviour of doctors was revealing too, but none made such open admission of personal learning.
Few promises were exchanged at that meeting but, crucially, a monthly multidisciplinary maternity forum helped by the same facilitator was agreed and followed. Forum members continued to confront and modify beliefs about others’ behaviour and received and acted on feedback about their own. The first forum was characterised by more conflict and heightened emotions. For instance, midwives vehemently defended their right to exclude doctors from the natural process of labour, while hospital specialists railed against lack of preparation of mothers for emergency surgery and anaesthesia. Building enough trust to identify shared goals and create an open learning environment was in the end helped by senior players openly allowing their own reactions to be explored and modified in the role of “vulnerable learner”. All of us had “hot buttons” and over reacted to certain issues. Feedback from the facilitator allowed us to recognise our behaviour and explore the often false beliefs underlying our reaction.
Over a 9 month period forum members developed effective ways of working together (box 2) and managed without the facilitator. Eventually this small representative group, exploring often strongly held opposing views, created collaborative solutions that made a difference. An autonomous quality improvement team was created and driven by the forum. An early success was resolving interprofessional conflict around induction of labour. Independent midwives agreed to allow hospital staff to manage induction so that they could focus on supporting women in established labour. Obstetricians and midwives jointly developed the protocols for the conduct of induction. Consumers in the forum rewrote the patient information leaflet in simpler form. Interprofessional relationships improved and eventually an atmosphere of friendly collaboration replaced the hostility. Morale and staffing levels improved and we currently have no staff vacancies in the maternity unit.
Box 2 Working of the multidisciplinary maternity forum
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Clear ground rules and skilled facilitation created safe learning environments.
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Issues were depersonalised: we focused on behaviour without attacking the person.
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Strong feelings were acknowledged and individual professional needs clarified.
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The wording of issues and resolutions was teased out in a collective process.
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Common goals were identified and respected—improving the care of mothers and babies.
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Through a gradual process of building trust, the voice of consumers was added to the forum and consumer centred solutions developed.
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The priority and strategies for all improvement were governed by the forum, with delegated authority from management.
Patients benefited too. Although we never set explicit goals for improvement in clinical outcomes, the gains are striking. The average caesarean rate has fallen a third over the last 2 years to 15.3% compared with the national rate of 22%. Our benchmarked neonatal APGAR scores are now among the best in Australasia (percentage of 5 minute APGAR scores ⩽7 has fallen from 6% to 1%). Patient complaints have reduced in number from an average of nine per quarter to two per quarter.
A HUMAN APPROACH TO LEADERSHIP AND CHANGE
All of this started 2.5 years ago. Our changes were fuelled by crisis. But what can others learn? Firstly, we would hope that no one experiences such a crisis of care and caring. Nevertheless, our experience suggests that understanding your own and others’ views and beliefs, valuing others’ contributions, and being open to challenge are as important to quality improvement as the possession of robust data if the aim is to make changes to working practices that lead to significant improvements for patients.
According to the Franklin reality model, life experiences lead to a set of beliefs that determine our personal actions and corresponding results.2
Most improvement effort focuses only on the actions required to produce different results. Given the conflicting beliefs of midwives and obstetricians (box 3), we knew that a rational scientific strategy for the reduction of caesarean sections that ignored the underlying beliefs would fail.
Box 3 Conflicting and interdependent belief systems
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The experience of midwives was that calling an obstetrician into the labour room commonly resulted in immediate caesarean section. The beliefs included:
– The obstetricians don’t care about the mother and baby
– They only want to do operations
– They regard the emotional and spiritual aspects of childbirth as unimportant
– If I consult with an obstetrician, he/she will take control and act against the mother’s wishes
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The corresponding beliefs of obstetricians and anaesthetists were:
– Midwives are willing to compromise clinical safety for emotional aspects of care
– Midwives give mothers unrealistic expectations about labour
– Mothers are denied helpful interventions such as augmentation of labour
– The doctors are left to deal with all the disasters and may be made accountable for the errors of midwives
Effective leaders focus efforts on creating new experiences that challenge personal beliefs and lead to new behaviours and new results. In adulthood, personal beliefs are relatively fixed and require a significant emotional event to change. In the role play workshop and subsequent forums we intervened in a dramatic way to expose conflicting beliefs and create new shared experience that reinforced common goals and collaborative behaviours. A high risk strategy for all, but particularly for the participants. None of this is for the faint hearted! Courage was required to manage high levels of interpersonal conflict, anger, and blame, but the expression of strong emotion was a necessary part of the process in changing beliefs.
Data alone are not enough. Information demonstrating that some aspects of care for many of our patients was wanting had been available to us for years. But combining data with an honest exchange of views was the key, for the very survival of the maternity unit was at stake. The question for others not at crisis point is how to initiate a climate of trust without having to experience such a crisis first.
We now create our own “crises” by exposing the undiscussable issues and defensive behaviours that are commonplace in any organisation. Currently we are exploring the contradictory world views of geriatricians and acute care physicians. The Franklin reality model is a great place to start. Just ask opposing camps to intuit what personal beliefs underlie the others’ observed behaviour and then feed back. Angry reaction? Observe, intuit, and feedback again.
The response to a crisis experienced in the maternity unit at Waitakere Hospital, New Zealand resulted in profound improvements in care