Trust Board papers November 2012 - Barking Havering and ...

Women’s Services
Exception Report for the Maternity Performance Dashboard and
Assurance Framework
September 2012
Red Areas
Guidelines
There are 12 guidelines which have expired; the reasons being:
An Increase has been noted from the previous month due to a large number of
guidelines expiring in September. Most of these have been updated but are waiting
approval or uploading onto the Intr@net.
Deliveries
There were a high number of deliveries at both units during September. This
continues a trend for the first six months of the year. Births are monitored very
carefully and escalation occurred as required. It is anticipated that births should start
to decrease in November due to an increase in the bookings in Barking being
undertaken by Barts Heath for the last five months. The case load transfer has been
delayed by a month to mid November. Discussions are ongoing with the
commissioners; the bookings have reduced over the last month.
Triage
The triage area on the Labour Ward at Queen’s Hospital achieved 88% in seeing women
within 30 minutes. As part of the continuous improvement programme the Triage
pathway has gone through several iterations including most recently in July 2012. This
process is continuing through the work of Maternity Clinical Fellows. It is anticipated the
service will settle with much higher percentages of women seen in 15 minutes once this
work is completed. Phase one of the new pathway commenced on 30 th July.
LSCS Grading.
This continues to be problematic with data recording and appropriate grading of
LSCS with only 54% achievement of grade 1 LSCS. It has been agreed that the clinical
director will identify one of the obstetric team to monitor the doctors to ensure that
they have completed the E3 at the time of LSCS, this will ensure that we have
accurate data. It will also ensure that we are able to accurately record the grading of
the LSCS and any inappropriateness will be addressed with individuals. We hope to
see an improvement in the next month’s figures. There were no poor outcomes
noted from the notes audited.