Abstract

The Antenatal Day Assessment Unit (ADU), the A and E of maternity services, in a central London tertiary hospital, was inspected and reported as having inadequate capacity and poor patient and staff experience. It offers an open-access, 24 hour walk-in service for urgent/emergency care.

We undertook an integrated, trust-wide care redesign programme (CRP) to transform the pathways and patient flow. Our team included consultant obstetricians, specialist trainees, midwives, a clinical coder/analyst, a change agent and maternity service manager, with support from the trust medical director and an international expert with Harvard Business School experience. The CRP consisted of structured sessions including principles of systems thinking, unwarranted variation, changing culture and leading transformational change. There was protected coaching, team-time and web-based resources. Key metrics were agreed and measured including time from attendance to assessment of the fetal heart, and measures of patient satisfaction.

A value proposition was co-produced, enabling us to focus our transformational efforts. Key stakeholders were consulted regarding potential new names for the unit better reflecting its function. Unscheduled care pathways were characterised, optimised and separated from scheduled care pathways. Changes were made to reduce waste (any process that did not directly add value to women).

A systems-wide approach has resulted in a sustained improvement in key metrics. The renaming of ADU to the Maternity Assessment Unit and the value proposition has enabled the team to implement change in a logical manner and visual representation of data has empowered frontline staff to engage in the transformational experiments. This required senior clinical leadership that is committed, visible and facilitative. The support provided by the medical director and trust executive team was crucial to enable the team to experiment and apply the principles of reducing unwarranted variation.