tuesday 30 june 2015, london

Maternity Services Data Set (MSDS) Stakeholder User Group

Tuesday 30 th June 2015, London

1

Community and Mental Health Team, Health and Social Care Information Centre

Welcome and Introductions

Tony ChildsProgramme Manager (Community and Children) )

2

Housekeeping

• Me• Fire Alarm• Toilets• Ask questions• Feedback (especially forms)

Welcome and Introductions

Tony Childs Programme Manager, Community and Children

Nicholas Richman Service Development Manager

Julia Webb Senior Datasets Maintenance Analyst

Sue Nowak Head of Pricing Development TeamNHS England

Hannah Knight Lindsey Stewart Centre for Audit and Clinical Informatics, RCOG

Dan O’Connor Acute Care Clinical Policy Unit, NHS England

Don Carter Senior Tester

Gary Sargent Bureau Services Manager

Jacqueline Dunkley-Bent

Interim Head of Maternity NHS England

Providers

System Suppliers

Maternity Pathway Payment

Sue NowakHead of Pricing Development Team, NHS England

5

www.england.nhs.uk

• The new payment system was introduced in April 2013 (thought work began in 2010)

Why?• Previous coding inconsistently applied by providers – considerable variation

in funding – not in line with need• Previous system encouraged more activity, but not necessarily better

outcomes for women• Multiple providers involved – but no overall accountability.

Maternity pathway payment

www.england.nhs.uk

Is it perfect?

Of course not!

We listen to comments and concerns

We have a National Review Group, chaired by Tracey Johnston

We issued supplementary guidance in August 2014

7

www.england.nhs.uk

Contents of supplementary guidance documentInclusions and exclusions from the pathway payments

• Early pregnancy unit and emergency gynaecology activity • Screening and immunisation • Fetal medicine• Coding specialist activity

Data flows, contracting and invoicing • Update on the national maternity dataset• Data flows for invoicing Determining the lead provider Contracting

issues • Handling income/expenditure on maternity across the year end

Appendix A: CSU support in implementing the maternity pathway payment

• Appendix B: Specialised Services Circular on specialised fetal medicine coding and charging for 2014/15

8

www.england.nhs.uk

Fetal Medicine

• Fetal medicine activity is currently coded to TFC 501 or generates NZ HRGs.• This activity cannot be distinguished from all other obstetric activity.• Tariffs are derived from costs of obstetric activity (including, by definition, fetal

medicine)• So the money for fetal medicine is in the tariffs.• The standard pathway tariff has been adjusted to take account of mothers

who develop complications. A fetal abnormality requiring fetal medicine is one complication

• Remember, tariffs are averages.

9

www.england.nhs.uk

Screening costs

• 3 newborn tests assumed to be in postnatal pathway (NIPE, blood spot and hearing screening)

• Can be (and are in most cases) directly provided.

• They are sometimes contracted out. It is up to the provider to manage the contract (but specified by NHS England). If expensive, may be cheaper to bring in house.

10

www.england.nhs.uk

There was concern about inconsistency

• We will provide further guidance for 2016/17• With the consultation version of the National Tariff Document for 2015/16

an annex was published (4B). It contained1. Technical guidance (data references in Maternity Data set etc)2. Definitions

11

www.england.nhs.uk

• We undertook a bespoke data collection in late 2014 to review the percentage of women in each pathway

• This was in response to concerns raised by a number of providers that there were more women in the intermediate and intensive pathways

• Our findings have led to a propose that we change the relativities for 2016/17

Checking the assumptions on relativities

www.england.nhs.uk

Oct – Dec data – from 6 providers

13

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

Non specialist Non specialist Specialist Specialist Specialist Non specialist

Standard

Intermediate

Intensive

www.england.nhs.uk

% of mothers allocated to intermediate pathway by factor

0

5

10

15

20

25

30

www.england.nhs.uk

Some factors were identified as missing from the a ntenatal pathway. These were set out in the 2015/16 consultation and have b een implemented by those providers accepting the Enhanced Tariff Offer and will be part of the 2016/17 package

NHS | Presentation to [XXXX Company] | [Type Date] 15

Factor Change

Cystic fibrosis Add to the intensive pathway

Previous organ transplant Add to the intensive pathway

Serious neurological conditions (not epilepsy as this is already in the intermediate pathway)

Add to the intensive pathway

Serious gastroenterological conditions Add to the intermediate pathway

Body mass index (BMI) >49 Add to the intensive pathway

Low pregnancy-associated plasma protein A (PAPP-A) reading

Add to the intermediate pathway

www.england.nhs.uk

• NHS England will be undertaking a review of the post-natal factors• NHS England is working with Monitor to carry out a bottom-up costing

exercise for maternity services to respond to the sector saying that the quantum for maternity services is not sufficient

• NHS England Monitor is working with the maternity review team to look at how the payment system can best support increased choice for women

• The introduction of the maternity dataset will be used to support payment and rewarding good outcomes and will help un the future with billing and correct identification of the lead provider and others delivering care for each woman

• NHS England is working with our clinical leadership to develop a best practice tariff and care bundle for Still Births

Future maternity pathway developments

www.england.nhs.uk

Email these to either:

NHS [email protected]@monitor.gov.uk

Questions

General Update and Status of Delivery

Tony ChildsProgramme Manager (Community and Children)

18

General update and status of delivery

Historic

• Delay due to difficulty obtaining funding• Funding approved• Maternity ISN was published in May 2014• System suppliers complied with the standard from

November 2014• Providers collected data locally from November

2014• First submissions began in May 2015 (for April

2015 data)• Pilot data was collected for testing purposes


Current status - general

• Submission window (Exeter portal) open for collection of April 2015 data from June 2015

• Window closes 31st July 2015• Currently there have been successful

submissions of data from 6 trusts• A further 22 trusts are in the process of

submitting some data• 39 trusts registered to submit, we continue to

chase trusts who are not yet registered


Current – Testing • Testing team undertaken Operational

Assurance testing (3 providers)– Demonstrated some issues (bug)– Will result in a requirement to update how the

data submitted through the portal is processed

– Impact on providers (data may change)– New dataset – changes / updates are likely to

be needed initially• Try to limit impact on providers


• Data submitted (early in window) 500 record accepted for post deadline processing

• Bug fix introduced (mid window)• Change to validation – 450 records would now be accepted• Providers informed may want to resubmit• Also, could be converse 450 records – now 500 accepted


Submission window• Could change in the future• Possibly 1 month primary then final

(refresh) submission the following month• Post deadline extract each month

– More timely data

• Update and see data – opportunity to update

• Ability to close the Portal window


XML conversion tool• SCCI mandated XML data submission

method• Developed initially at testing stage• Provided as an option to help with XML

data submissions• Unfortunately, not supported centrally• Feedback forms

Feedback session

Nicholas Richman, Service Development ManagerJulia Webb, Senior Dataset Maintenance Analyst

25

Group Feedback session

• Important - Managing further dataset developments

• Top 3 issues encountered• Top 3 what went well• Consider all stages – documentation,

implementation, submission, collection, extraction, etc.

Lunch

12.30pm to 1.30pm

27

System Supplier presentationsWellbeing Software Group (Euroking)

Steve Avery

28

MSDS Implementation Overview

What We Were Asked To Do

Ensure EuroKing Maternity Information System

“E3.Net” was able to collect appropriate data

items as specified by HSCIC

We Achieved This By:

Using the in-built system localisation tools to add

and update existing Questions and Answers

where appropriate

Developing a suite of in-built system reports to

provide a data extract and guidance for users in

understanding their data for submission

Approach

(from development and clinical perspective)

• All sites/questionnaires assessed on an individual basis to

review localisation required and updated accordingly

• Development planned to produce reports that system

managers could use to analyse data prior to submission

• Intention to provide a mechanism to extract data from report

into expected XML format as per HSCIC specifications

• Did not want/need to use a third party for the XML conversion

• Wanted to enable customers to be able to extract data either

for Open Exeter submission or to import into the HSCIC XML

Conversion tool

Problems Encountered

• Significant time overhead to assess each customer and make

updates

• Mapping existing customer localisations on a case by case

basis to data requirements took a considerable amount of

time

• Clients did not seem aware of the changes proposed by HSCIC

and we found ourselves updating them regarding the MDS

process

• Frequency of spec changes from HSCIC

• Client reluctance to change/adapt

• No test environment available

What went well

• Customer acceptance of our approach

• Customer approval of reporting enabling data to be extracted

for both Open Exeter and the HSCIC Conversion Tool

• Good feedback from HSCIC technical team assisting with

queries on dataset and XML formatting to support

development processes

IMPLEMENTATION

How we implemented itAll customer site questionnaires updated with MDS relevant questions and answers

to ensure the relevant scope of data capture was correct.

Four reports developed in SQL Server Reporting Services:

• A User Guide to act as a reference for system managers to understand their

MDS data and MDS reports,

• A mapping report to show how data items were retrieved from the system

• A Code Mapping report to show how data items are linked to the clinical

data in the system.

• A Missing Mandatory Answers report to show where mandatory answers

are missing from a potential set of data to be submitted so these can be

corrected by the system administrator prior to submission.

• The MDS Preview report which contains the MDS data extract. From this

report an XML file can be generated to be submitted either to Open Exeter

or used in the HSCIC XML Conversion Tool.

Problems encountered

• On-going discussions between suppliers, providers

and HSCIC regarding data item changes needed to be

accounted for in development both technically and

clinically

• Technical issues rendering generating XML files from

SQL Server Reporting Services during the

development phase

What went well

• The reports have been well received by customers

especially the level of detail available to enable

system managers to check data prior to submission

• Project planning of roll out – willing Trusts

• HSCIC responsiveness to queries

THE FUTURE

• Depends on feedback from the first submission window

• Reports have been designed to be flexible enough to be easily

amended based on expected customer feedback once the

process becomes more familiar

• Reports can also be amended and re-configured where

required based on any MDS dataset updates from HSCIC

• Possibility to include “other” data (i.e. GP data) in submission

• Through this process EK has put processes in place to improve

communication to all customers when changes of this nature

are announced

• Discussion welcomed on change management and where the

responsibilities lie between supplier, provider and HSCIC

System Supplier presentationsHD Clinical

Andy Dawson

41

Andy Dawson

Research & Development Director

◦ Introduction

◦ Analysis

◦ Trust Engagement

◦ Obstacles to implementation

◦ Implementation

◦ Data recording

◦ MSDS Extract format

◦ Initial experience of data submission

◦ Conclusion

◦ HD Clinical (HDC) are a leading supplier of clinical systems – primarily Maternity and Cardiology

◦ CMiS - Maternity System◦ Solus Enterprise:◦ Cardiology◦ Maternity – in development◦ Mobile functionality

◦ Working closely with our customers to implement MSDS in CMiS◦

� Gap analysis - Initial review of MSDS v CMiS

� Areas of difference between CMiS and MSDS:

� Some data not recorded – added as required

� Free text changed to option list

� Tests not routinely offered by Trusts (MAT210 Mother’s Asymptomatic Bacteriuria Screening Offer)

� Items where MSDS options did not match local reporting (MAT211 Mother’s HaemoglobinopathyScreening Test)

Haemoglobinopathy Screening – mapping local reporting to MSDS

Still trying to get clarity from Labs/Screening Co-ordinators.

Haemoglobinopathy Screening – mapping local reporting to MSDS

� CMiS National User Group meetings

� MSDS Special Interest Group meeting

� Individual Development Trusts

Hurdles to overcome:

�Timing – NN4B/PDS priority – delayed MSDS work

�Lack of funding:

� Impact on suppliers to implement changes

� Impact on Trusts to upgrade software/new

technology

� Impact on Trusts to provide staff to record data

� Some Trusts only recently able to turn attention

to MSDS

� HDC made MSDS compatible version of CMiS

available to Trusts FOC

� All Trusts have MSDS version on their QA

systems

� Not all have gone live yet with MSDS extract

capability (staffing issues, change control)

◦ Optimistic – Most Trusts will be before 31st July

◦ Some Trusts NOT set up to collect full dataset

e.g. Community Contacts/Activity

◦ CMiS records all contacts & associated clinical data

◦ Solus Mobile App for CMiS enables POC data

collection

�Trusts awarded NTF o.k.

�Some Trusts struggling to find finance

Creating the extract

I. Initially provided CMiS MSDS extract as XML file

for direct submission (used HSCIC XML schema

& conversion tool as guide)

II. Some Trusts required CSV option

� to merge with data from other sources e.g.

antenatal appointments

� to merge with data from another hospital within Trust (some using different maternity system)

Initial experience of data submission:

� Baby’s Date of birth – requires seconds!

� MAT307 medical diagnosis: multiple records for different diagnoses rejected – call logged with HSCIC

� MAT201 blood group test – valid data rejection -‘If SAMPLE DATE is populated and is before BOOKING APPT DATE (from MAT101), then the group will be rejected’

� CMiS enables the recording and extract of the

data for MSDS

� Ongoing discussion with Trusts on the recording

of some items

� Still challenges for Trusts, particularly in the

Community, but focus is firmly on MSDS now

Lessons learnt

� NHS/HSCIC to plan significant changes

(avoiding clashes e.g. NN4B-PDS, MSDS & now

FGM extended dataset)

� Recognise costs to supplier and Trust

� Provide financial support/incentives

The Importance of a National

Maternity Services Dataset:

A Clinical Perspective

Hannah Knight,

Clinical Quality, RCOG

© Royal College of Obstetricians and Gynaecologists


What does the RCOG use

national maternity data for?

• Clinical and epidemiological research

examining trends, variations and inequalities

in maternity care – which in turn informs our

national clinical guidelines1

• Monitoring the quality of care and

performance of units

• National audits, quality improvement and

surveillance projects1 https://www.rcog.org.uk/guidelines


Recent RCOG publications using

HES maternity data


RCOG Clinical Indicators Project


0

10

20

30

40

50

60

70

80

women living in a

socially deprived

area

women in an ethnic

minority group

0

1

2

3

4

5

6

women aged 15-19 women aged over 40

The Importance of Risk

AdjustmentStoke Mandeville Birmingham Women’s

% %


Risk-adjustment

MethodologyRisk Factors avaiable in HES:

Maternal age

Ethnicity

Deprivation quintile

Previous Caesarean section

Gestational age

Birthweight

Pre-existing hypertension

Pre-existing diabetes

Gestational diabetes

Pre-eclampsia/eclampsia

Placenta previa/abruption

Fluid abnormalities

Requires patient-level data on key risk

factors

Multiple logistic regression calculates

the odds of an outcome for each

woman in the sample based on her

individual risk factors

Summed at hospital level to give the

expected rate

The adjusted rate is calculated by

dividing the observed by the expected

rate and multiplying by the national

mean

•

•

•

Case-mix adjustment:

•


Funnel plots1 in 20 hospitals would

be outside the inner

funnel by chance alone1 in 500 hospitals would

be outside the outer

funnel by chance alone

National mean


Impact of risk-adjustment:

Example - Elective Caesarean Section

(multiparous women)

05

1015

2025

Ele

ctiv

e C

S r

ate

(%)

0 1000 2000 3000 4000

Number of multiparous deliveries per year

English average 95% limitsHospital rate 99.8% limits

Mean: 12%

Range: 1-20%

10th percentile: 9%

90th percentile: 16%

Before


05

1015

2025

Ele

ctiv

e C

S r

ate

(%)

0 1000 2000 3000 4000

Number of multiparous deliveries per year

English average 95% limitsHospital rate 99.8% limits

Mean: 12%

Range: 1-16%

10th percentile: 9%

90th percentile: 14%

Impact of risk-adjustment:

Example - Elective Caesarean Section

(multiparous women)

After


Indicator

Subset of

population

used *

National

mean (%)

Mean of

bottom10% of

units (%)

Mean of

top 10% of

units (%)

Induction of labour rateP,S,T,C 27.5 16.9 38.1

M,S,T,C 21.4 13.5 29.9

Percentage of induced labours resulting in emergency caesarean sectionP,S,T,C 30.2 20.4 40.3

M,S,T,C 13.2 5.8 22.1

Percentage of spontaneous labours resulting in emergency caesarean

section

P,S,T,C 11.6 7.0 17.2

M,S,T,C 6.2 2.9 9.2

Elective caesarean section rateP,S,T,C 2.8 1.2 5.0

M,S,T,C 12.1 7.2 15.0

Percentage of elective caesareans performed before

39 weeks of gestation without clinical indicationS,T 30.3 18.0 52.5

Instrumental delivery rateP,S,T,C 24.2 16.4 31.8

M,S,T,C 7.5 3.8 11.5

Percentage of instrumental deliveries carried out by vacuum extraction

(vacuum:forceps delivery ratio)S,T,C 49.3 24.2 72.1

Percentage of attempted instrumental deliveries resulting in emergency

caesarean sectionS,T,C 3.1 1.1 7.0

Third and fourth degree perineal tear rate amongst unassisted vaginal

delivery

P,S,T,C 4.0 2.0 6.8

M,S,T,C 1.4 0.6 2.4

Third and fourth degree perineal tear rate amongst assisted vaginal

delivery

P,S,T,C 6.9 3.0 11.0

M,S,T,C 2.5 0.4 4.6

Emergency maternal readmission within 30 days of deliveryS,T,C,V 0.8 0.3 1.6

S,T,C,CS 1.4 0.3 3.4

National Variation in Maternity Care

(based on HES data)

P – primiparous; M – multiparous; S – singleton; T – term; C – cephalic; V – vaginal; CS – caesarean section


Impact on clinical practice

• This was the first time hospitals had received back their own maternity data,

risk adjusted for differences in case mix – to be repeated later this year

• Feedback suggests results were used as a tool for benchmarking, reflecting

on local team performance and for raising awareness of local data quality

issues

• Strategic Clinical Networks held quality improvement workshops to compare

results among hospitals within the region

• Data quality issues have been fed back to Trusts. This is expected to lead to

data quality improvements in subsequent years.

• NICE have recommended our ‘elective CS <39 weeks’ indicator for the CCG

Outcomes Indicator Framework

• The CQC have adopted several components of our methodology to improve

their Maternity Outliers Surveillance Programme

• The National Audit Office used several of our definitions and our risk-

adjustment methodology in the recent ‘Maternity Services in England’ report


So why is HES not enough?

• The HES maternity tail items focus on the intrapartum period, whereas the MSDS covers the whole maternity pathway, from antenatal booking through to the postnatal period.

• HES does not allow us to link the mother and the baby’s records, so we cannot examine the impact of care during pregnancy and delivery on neonatal outcomes

• Several important data items are not captured in HES, e.g.– Maternal BMI (Height and weight)

– Maternal smoking status (at booking and discharge)

– Booking date

– Time of birth

– Postpartum blood loss (ml)

• Problems of missing data e.g. birth weight, gestational age, parity and onset of labour – DQ issues (HES) for specific trusts


Key questions that the

MSDS could address

Important areas of national health policy:

• Impact of planned place of birth on maternal and

neonatal outcomes. MSDS would allow us to repeat

the recent Birthplace study on an ongoing basis

• 24-hour staffing: impact of time of birth on maternal

and neonatal outcomes

• Impact of mother’s care on baby’s longer-term

outcomes - linkage with CYPHS dataset opens up

numerous possibilities


Final remarks

• The MSDS is a long awaited and highly anticipated

resource within the specialty

• Complete, high quality data on every pregnancy

pathway will be key

• The MSDS will also be a key source of data for the

National Maternity and Perinatal Audit that will be

rolled out from 2016

Saving Babies’ LivesReducing stillbirth and early neonatal death: a care bundle

Dan O’ConnorProject Manager, Medical Directorate, NHS England

Purpose of this presentation

• Establish why we are doing this

• What we’ve achieved so far

• What’s happening now

• What will be done next and over the coming year

• Care bundle approach, and elements and interventions

• Obviously, focus on the data availability and need

74

Why are we doing this?

• Stillbirth rates in England / UK remain among the worst of high income countries / Europe and only small improvement in 20 years

• Mandate and NHS Outcomes Framework: Reducing deaths in babies and young children

(1.6.ii Neonatal mortality and stillbirths)

• “Care bundle” approach suggested as effective means to drive improvement.

75

Care bundle

Care bundle:

A group of interventions (or elements), usually 3-5, which focus on a specific disease process or patient group, that when implemented together, deliver better outcomes than if implemented separately

(Institute for Healthcare Improvement)

Elements ought to be:

• Evidence based/widely recognised as good practice – no controversy

• Straightforward to implement

• Part of day to day practice

• All the interventions are necessary. If you removed one – the chance of success not as high

76

What we’ve achieved so far

• Strong stakeholder engagement and consensus building to determine that this is the right approach

• “Developed” the care bundle: inclusive development of care bundle in draft, on paper, through four multi-organisational task and finish groups

• Engagement with 12 Strategic Clinical Networks in England to spread message about the bundle and promote early implementation

• Around 50 per cent of providers that responded are keen to be involved and some to take part in test and trial

77

Partial list of stakeholders

78

Child & Maternal Health Intelligence Network, Public

Health England (PHE)

West Midlands SCNCheshire &

Merseyside SCNPerinatal Institute

Tobacco Control Team, PHE

North East SCNHealth and Social Care Information Centre (HSCIC)

Leeds Teaching Hospitals

Maternity and Starting Well Branch,

Department of Health London SCN Bliss

Manchester Academic Health Science Centre

(MAHSC)

Royal College of Midwives (RCM)

Yorkshire & Humber SCN

MAMA AcademyHealthcare

Improvement Scotland

Royal College of Obstetricians and

Gynaecology (RCOG)South East Coast SCN

Sands (Stillbirth and Neonatal Deaths

Charity)

British Maternal FetalMedicine Society

Manchester Strategic Clinical Network (SCN)

Wessex SCN Tommy’s Count the Kicks

What’s happening now?

• Providers expressing their interest in becoming early implementers for the test and trial phase

• Developing a comprehensive implementation toolkit

• Working group on data to tackle data issues

• Formal evaluation specification being devised

79

What will be done next?

• At high-level: test the care bundle, refine, roll-o ut

• Ideally roll-out April 2016 onwards

• Publish the Toolkit in Oct 2015

• Undertake the formal evaluation

• Data group and wider data and information system to devise solutions to data issues and inform work to develop financial tools e.g. Best Practice Tariff

80

Proposed elements

81

Smoking cessation

Reduced fetalmovement

Identification and

surveillance of fetalgrowth

restriction

Fetalmonitoring

during labour

Smoking Cessation

Element

Reducing smoking in pregnancy by carrying out Carbon Monoxide (CO) test at antenatal booking appointment to identify smokers (or those exposed to tobacco smoke) and referring to stop smoking service/specialist as appropriate

Intervention

Carbon monoxide (CO) testing of all pregnant women at antenatal booking appointment and referral, as appropriate, to a stop smoking service/specialist, based on an opt out system. Referral pathway must include feedback and follow up processes.

82

Element 1

Process and Outcome Indicators

Intervention Indicators

• Carbon monoxide (CO) testing of all pregnant women at booking and referral to stop smoking service/specialist, based on an opt-out system

• Recording of smoking status of each pregnant woman

• Recording of CO reading for each pregnant woman

• If this identifies exposure to smoke or a high CO reading, referral to stop smoking service (or other action)

• Number/rates smoking at booking

• Number of smokers setting a quit date

• Number quit at 4 weeks from quit date (CO validated)

• Number quit at 12 weeks if data available (CO validated)

• Smoking at time of delivery (SATOD)

83

Fetal Growth Restriction

84

Element 2

Element

Identification and surveillance of pregnancies with fetal growth restriction

Interventions

1. Use of customised antenatal growth charts for all pregnant women by clinicians who have gained competence in their use

2. Use of supplied algorithm to aid decision making on classification of risk, and corresponding screening and surveillance of all pregnancies according to their risk

3. Ongoing audit and reporting of Small for Gestational Age (SGA) rates and antenatal detection rates

4. Ongoing case-note audit of selected cases not detected antenatally, to identify barriers


Intervention Process Indicators Outcome Indicators1. Use of customised antenatal growth charts for all pregnant women by clinicians who have gained competence in their use

• Customised growth charts implemented

• Training programme on use of charts in place

• Fundal height and scan estimated fetal weight measurements plotted

• Charts generated for each pregnancy

• All staff competent in use of customised growth charts, and audited within Trusts e.g. through midwifery supervision/trust based training and competence records

2. Use of supplied algorithm to aid decision making on classification of risk of SGA , and corresponding screening and surveillance of all pregnancies according to their risk

• Algorithm to classify risk is part of unit protocol

• All staff trained in use of algorithm

• Proportion of pregnancies appropriately screened / surveilledaccording to risk

3. Ongoing audit and reporting of Small for Gestational Age (SGA) rates and antenatal detection rates

• Completion of postnatal audit using GROW or trust management information systems (MIS)

• Increase/decrease of antenatal referral rate and detection rate of babies SGA at birth, including true and false positives

• Decrease/increase of stillbirths with SGA

4. Ongoing case-note audit of selected cases not detected antenatally, to identify barriers

• Appropriate process of selecting for review - e.g. 10 cases each 6 months

• Barriers identified; learning from audit is fed back into processes to drive improvement

85

Reduce Fetal Movement

86

Element 3

Element

Raising awareness amongst pregnant women of the importance of detecting and reporting reduced fetal movement (RFM), and ensuring providers have protocols in place, based on best available evidence, to manage care for women who report RFM.

Interventions

1. Information and advice leaflet on reduced fetal movement (RFM), based on current evidence, best practice and clinical guidelines, to be provided to all pregnant women by, at the latest, the 24th week of pregnancy and RFM discussed at every subsequent contact.

2. Use provided checklist to manage care of pregnant women who report reduced fetal movement, in line with RCOG Green-top Guideline 57


Intervention Process indicators Outcome indicators

1. Information and advice leaflet on reduced fetal movement (RFM), based on current evidence, best practice and clinical guidelines, to be provided to all pregnant women by, at the latest, the 24 th week of pregnancy and RFM discussed at every subsequent contact.

• Leaflet given to and discussed with all pregnant women by 24th week of pregnancy

• Feedback obtained from sample of women to gauge whether messages have been assimilated as intended

2. Use provided checklist to manage care of pregnant women who report reduced fetal movement, in line with RCOG Green-top Guideline 57

• Protocol in place, that follows checklist, for care for pregnant women who report RFM

• Care for all pregnant women who report RFM managed according to checklist

• Stillbirth rate (decrease/increase)

• Induction rate (increase/decrease)

• Percentage of women reporting RFM who have 1. further action 2. no further action

87

Fetal monitoring during labour

88

Element 4

Element

Effective fetal monitoring during labour

Interventions

1. All staff who care for women in labour are required to undertake an annual training and assessment on cardiotocograph (CTG) interpretation and auscultation. No member of staff should care for women in a birth setting without evidence of training and competence within the last year.

2. Buddy system in place for review of cardiotocograph (CTG) interpretation, with a protocol for escalation if concerns are raised. All staff to be trained in the review system and escalation protocol.



1. All staff who care for women in labour to undertake an annual training and assessment on cardiotocograph (CTG) interpretation and auscultation. No member of staff should care for women in a birth setting without evidence of competence within the last year.

• Number of staff who have received training on CTG interpretation and auscultation

• Number of staff who are deemed competent in CTG interpretation and auscultation

• Number of staff who have successfully completed mandatory annual updates on CTG interpretation and auscultation

• (denominator for each indicator: total number of labour ward staff at trust whose role includes the care of women in labour.)

• Intrapartum stillbirth decreases

• Number of admissions to neonatal intensive care unit as a result of HIE decreases

89



2. Buddy system in place for review of cardiotocograph (CTG) interpretation, with protocol for escalation if concerns are raised. All staff to be trained in review system and escalation protocol.

Buddy system used in all intrapartumCTG interpretation according to local protocol

Sticker system used according to guideline for all women in labour undergoing CTG monitoring

Escalation protocol in place and used appropriately

(documentary evidence required for each indicator)

Intrapartum stillbirth decreases

Number of cases of Hypoxic Ischemic Encephalopathy (HIE) where baby requires cooling decreases

Early neonatal death within first seven days decreases

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Data needs

• Will be difficult to monitor activity and compliance with care bundle without easy access to electronically recorded data

• Data is being collected in different formats, in different bespoke systems which makes data collation even more difficult

• Nobody wants a bespoke collection

• Ideal to start working on developing indicators for Dataset

• Also, a Best Practice Tariff would require streamlined reporting against standards / objectives to ensure payment

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Another priority area: PIMH

• Perinatal and Infant Mental Health

• Extra 75 million over 5 years

• NHS Benchmarking Network doing some bespoke analysis

• Important to strengthen the data collection and reporting as we progress the work

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Thank you

Dr Dimitri Varsamis, Programme Manager

Acute Care Clinical Policy and Strategy Unit,

Medical Directorate, NHS England

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Future Payment Mechanism Developments

Update on Payment Mechanism Nicholas Richman, HSCIC

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Updates to Payment Mechanism

• Additional Medical History at Booking codes– Cystic fibrosis (in woman)– Previous organ transplant– Previous uterine surgery– Epilepsy requiring anti-convulsants

Link to NHS England Proposal for Change


• Expansion of Complex Social Factors from an indicator to the following values– Homeless– Recent migrant (last 12 months)– Refugee or asylum seeker– Learning Disabilities– Domestic abuse– Safeguarding– Can’t speak or understand English


• Additional Down’s Syndrome Screening Test Result (PAPP-A)

• Additional Previous Obstetric History codes– Placenta accreta– Intrauterine growth restriction– Previous fetal congenital anomaly that

required specialist fetal medicine input

Benefits of Change

• Provide a more granular understanding of needs and costs

• Without these changes the revised payment allocations can not be calculated

• NHS England may require that an additional data flow be established to capture the information if the changes aren’t included

Other Future Developments

Updates to the Maternity Services Data Set Nicholas Richman, HSCIC

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Amendments to the v1.5 data set

• Extend Local Patient Identifier to max an20• Moving ‘Presentation at Onset of Labour’ from

MAT404 to MAT502 and rename ‘Presentation of Fetus’?

• Mother’s smoking status at labour• Update definition of Booking Appointment to

clarify inclusion of initial appointments• Introduce Pregnancy ID as a linking item• Possibly include Booking and Delivery IDs• Add Postnatal appointments• Add time to admission and appointment tables

Requested Additions

• Female Genital Mutilation (FGM) – Currently flowing as a separate data set– MAT307 Medical Diagnosis (or booking

tables?)– Clinical Coding approach

Link to FGM standard

Indicative Timescales

• Publication of revised ISN late 2015

• Revised data set mandated from April 2016

• Potential for yearly updates

Further Ahead - Clinical Terminology

• Diagnosis tables– MAT102 Complicating Medical Diagnosis at

Booking– MAT103 Previous Complicating Obstetric

Diagnosis at Booking– MAT104 Family History Diagnosis at Booking– MAT307 Medical Diagnosis– MAT309 Maternity Obstetric Diagnosis– MAT510 Neonatal Diagnosis

• Screening tests

Example of a Clinical Coding Structure

Includes following data items:• Local Patient Identifier (mandatory)• Diagnosis Scheme in Use (mandatory):

• ICD 10• Read 2• CTV 3• SNOMED CT

• Diagnosis (mandatory)• Diagnosis Date (required)

Clinical Terminology Benefits

• Flow data as it is captured by clinicians• Analysis is internationally comparable• Analyse new aspects without making

changes to data set structure• Clinical terms are updated every 6 months• Able to respond more quickly to changes in

payment mechanism• Supports national drive to move towards

SNOMED CT enabled systems

Any further questions?

Questions and Answers session

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Close and summary

Tony Childs

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Close and summary

• Thank you• Main points

Please send all queries to:[email protected]

tuesday 30 june 2015, london

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