Improving maternal satisfaction with labour analgesia - a patient-centred approach

Dr Samuel Nava, ST3 Clinical Fellow in Anaesthesia, Dr Lesley Jordan, Consultant in Anaesthesia, Royal United Hospitals Bath

PLAN, PLAN, PLANà DO à STUDY à ACT

Introduction

Labour is a unique physical and emotional experience that can have a lasting impact on parents' lives. An important role for clinicians, particularly anaesthetists, is to provide analgesia for women in labour and support shared decision making [1].

We have undertaken a quality improvement (QI) project with the aim of improving maternal satisfaction with labour analgesia in a District General Hospital Consultant-led maternity unit. Below we outline the steps we have taken so far and the QI tools we have applied. The project was commenced in conjunction with completion of the NHS Quality, Service Improvement and Redesign course locally.

Baseline evaluation – understanding the scope

The aim of improving maternal satisfaction is extremely broad. We started by attempting to understand more about the contributing factors to satisfaction or dissatisfaction with labour analgesia, demonstrated in the driver diagram seen below. We aimed to concentrate on the aspects that have the greatest influence on choice or effectiveness of labour analgesia and we began with a baseline evaluation of patient experience.

We created a unique patient survey with input from a range of different multi-disciplinary stakeholders and invited women to reflect on the positive experiences of labour. The survey was published on social media, open to parents who had been through labour and given birth at our unit in the previous year. We received over 250 responses in 3 weeks. The survey included a broad range of questions and asked respondents to rank the factors that most significantly contributed to their choice of analgesia.

Driver diagram and the Pareto Principle

The initial questionnaire provided a wealth of information about patient experience. The survey describes most frequently used forms of analgesia and the most cited positive or negative aspects of labour analgesia. Through a modified application of the 20:80 Pareto principle, we have identified the key contributors to choice of analgesia as effectiveness, risk and side-effects such as nausea, vomiting or dizziness.

The driver diagram outlines the overall aim, primary and secondary drivers. We applied the results of the survey to the driver diagram and have progressed to plan a series of smaller quality improvement projects focused on the key drivers. We will apply small step wise changes though plan-dostudy-act cycles and frequent sampling.

Overall measurement of “satisfaction with labour analgesia” is difficult, however, we believe that by concentrating on more specific and measurable aspects of labour experience we can demonstrate quality improvement.

Stakeholder engagement

It became increasingly clear that this project would affect a breadth of individuals, from patients to members of the multi-disciplinary team. We have engaged high-impact and high-power stakeholders throughout and had positive input that helped in several ways:

- Understanding different perspectives. It has been invaluable hearing directly from patients and the Maternity Voices Partnership alongside our more medical perspective

- How best to gain valuable information from a patient survey. The trust patient experience team guided and supported with their service evaluation infrastructure

- Sustainability of change. With the aim of bringing lasting change, it has been important to engage senior leaders within the relevant departments to support sustained change

Action plan - Plan plan plan, now do study act!

We plan on a series of interventions:

- optimising our epidural regimens and reducing failed or inadequate epidurals

- increasing the availability of alternative analgesia such as remifentanil patientcontrolled analgesia

- improving the availability of antenatal learning resources

- heightening awareness of sustainability

Learning points

-We spent a lot of time trying to understand the scope of the project before starting and strongly encourage a similar approach for anyone planning future QI projects.

-We found using a driver diagram helpful to structure our ideas and applied of the Pareto principle to a baseline survey as a method of targeting efforts towards the most important interventions.

-We have learnt about the importance of stakeholder engagement, not only in providing valuable input but also in supporting sustainability of change