Quality Improvement, Change Management, Sustainable Healthcare & Digital Practice

Quality Improvement, Change Management, Sustainable Healthcare & Digital Practice

The Future Midwife standards expect midwives to understand quality improvement (QI) methodologies (5.1), to work with women, families and advocacy groups to develop improvement strategies (5.3), to understand sustainable health care (5.10) and change management (5.11), and to use digital technologies responsibly to access, record and share data (5.12, 1.23).

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Quality Improvement

Quality improvement is a systematic approach to making care safer, more effective, more person-centred, timely, efficient and equitable. Unlike audit, which checks practice against a standard, QI uses repeated small tests of change to find out what works locally.

The Model for Improvement

The Model for Improvement, widely used in the NHS, starts with three questions:

1. What are we trying to accomplish? A clear, measurable aim (for example, "increase the proportion of women offered skin-to-skin contact within 1 hour of caesarean birth from 60% to 90% by June").
2. How will we know that a change is an improvement? The measures used.
3. What changes can we make that will result in improvement? Ideas from staff, women and the evidence.

Changes are then tested using Plan-Do-Study-Act (PDSA) cycles:

• Plan: decide what to test, predict what will happen and plan data collection.
• Do: carry out the test on a small scale (for example, one shift or one theatre list).
• Study: analyse the data and compare with the prediction.
• Act: adopt, adapt or abandon the change, then plan the next cycle.

Measuring Improvement

• Outcome measures: the result for women and babies (for example, rates of hypothermia in term babies).
• Process measures: whether the steps are happening (for example, the proportion of babies with a hat applied within 5 minutes).
• Balancing measures: unintended effects elsewhere (for example, delays in other theatre cases).

Data are plotted over time on run charts or statistical process control (SPC) charts, which distinguish common cause variation (the normal background noise in a process) from special cause variation (a signal that something has changed).

Useful QI Tools

• Process mapping: drawing each step of a pathway to find delays and duplication.
• Fishbone (cause-and-effect) diagrams: grouping the possible causes of a problem.
• Driver diagrams: linking the aim to primary and secondary drivers and change ideas.
• Stakeholder analysis: identifying who is affected and how to involve them.

National maternity programmes use these methods. For example, the national PReCePT programme used QI to increase the use of magnesium sulfate for fetal neuroprotection in preterm births.

Co-Production with Women and Families

Improvement is most effective when it is co-produced with the people who use the service. Maternity and Neonatal Voices Partnerships (MNVPs), complaints, surveys and 15 Steps walkarounds help services understand what matters to women, especially those whose voices are seldom heard.

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Change Management

Change in health care often fails because people are not engaged. Common models include:

• Lewin's three-stage model: unfreeze (create readiness by explaining why change is needed), change (introduce the new practice with support and training) and refreeze (embed it in policy and routine).
• Kotter's eight steps: create a sense of urgency; build a guiding coalition; form a strategic vision; enlist a volunteer army; enable action by removing barriers; generate short-term wins; sustain acceleration; institute change.
• Rogers' diffusion of innovations: people adopt change at different rates, from innovators and early adopters to the early majority, late majority and laggards. Engaging respected early adopters helps spread change.

Midwives at every level lead change by understanding the evidence, involving colleagues early, listening to concerns, piloting changes, sharing results and recognising that resistance often reflects real worries about workload or safety.

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Sustainable Health Care

Climate change is a threat to health, and the health service itself produces a significant share of the UK's carbon emissions. In 2020, the NHS committed to becoming the first net zero national health service:

• Net zero by 2040 for the emissions it controls directly (the NHS Carbon Footprint).
• Net zero by 2045 for the emissions it can influence (the NHS Carbon Footprint Plus, including the supply chain).

The Health and Care Act 2022 gave NHS bodies duties to contribute to these targets.

Principles of sustainable clinical practice include:

1. Prevention: preventing ill health reduces the need for resource-intensive care (for example, smoking cessation and breastfeeding support).
2. Empowering people: supporting women to manage their own health.
3. Lean service delivery: removing waste and duplicated appointments.
4. Low-carbon alternatives: choosing options with lower environmental impact where clinically equivalent.

Examples in maternity care include:

• Nitrous oxide (Entonox) is a potent greenhouse gas. Services are reducing waste from leaking piped systems and ensuring scavenging and good practice, while still offering women effective pain relief.
• Reducing unnecessary single-use items and printing, and using reusable equipment where safe.
• Using remote or digital appointments where appropriate to reduce travel, while ensuring face-to-face care when needed.
• Ensuring medicines are not wasted, for example by checking stock and returning unused medicines safely.

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Digital Technologies and Data

Midwives increasingly use electronic patient records, digital maternity notes accessed by women on their phones, remote monitoring and video consultations. Responsible use requires:

• Information governance: the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018 require personal data to be processed lawfully, fairly and securely. The Caldicott principles guide when and how confidential information is shared, including the principle that the duty to share information for individual care is as important as the duty to protect confidentiality.
• Security: never sharing smartcards or passwords, locking screens, and accessing only the records of women in your care.
• Accurate, timely documentation: digital records must be contemporaneous, clear and attributable, just like paper records.
• Data quality: national data sets such as the Maternity Services Data Set depend on accurate recording, and errors can distort safety monitoring.
• Digital inclusion: some women lack devices, data or digital skills, so information must also be available in other formats and languages.
• Professional use of social media: the NMC's guidance on social media reminds registrants that the Code applies online. Midwives must not post information or images that could identify women or babies, and must maintain professional boundaries.
• Emerging technologies: tools such as decision-support software and artificial intelligence must be used within local governance, with the midwife remaining accountable for her decisions.