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Obstetricians' approach to proactive safety management

Blog 13 August 2021

A view from the outside: RCOG business manager Farrah Pradhan talks about her learning from undertaking a Master’s degree in Patient Safety.

Farran Pradhan thumbnailMy first encounter with an obstetrician was 21 years ago when I was pregnant with my first baby. The attention and kindness that I received by the obstetrician and his team were incredible; I was cared for with gentleness and understanding. He spoke to me with compassion, and in moments of delivering uncertain news, he placed his hand on my shoulder, showing his empathy for my circumstances. My baby was born 12 weeks early and although a very traumatic experience, this opened my eyes to a caring profession that surpassed any expectation that I could ever have imagined.

Working for the Royal College of Obstetricians and Gynaecologists, gave me the privilege of witnessing more of these encounters. I visited maternity units, listening and watching obstetricians and their colleagues work tirelessly for women and their babies against a backdrop of complexity and variation.

However, while the NHS offers some of the safest maternal outcomes in the world, there remains a worrying variation in the quality of maternity care, which means that the safe delivery of a healthy baby is not experienced by all.

Intrigued by this, I pursued a Master’s degree in Patient Safety. I wanted to understand what it was that gave some obstetricians this skill; to work effectively while maintaining a constant awareness of situations, identifying and managing emergencies and providing day-to-day care, all at the same time.

My dissertation focused on obstetricians’ use of proactive safety management concepts (termed Safety-II). This approach includes looking at 'work as done’. These are the adjustments, compromises, workarounds, actions and decisions that obstetricians make, to meet the needs of the women and people they care for and to keep them safe. Obstetricians have to make prompt decisions, organise multiple activities and co-ordinate care rapidly, all within an already complex system. ‘Work as done’ is achieved through a combination of expertise, clinical decisions, experience and tacit knowledge and it is because obstetricians vary their performance, depending upon changing circumstances, that allows the system to function.

Studying ‘work as done’ brought insights into how obstetricians build adaptive capacities when working in complex settings. This adaptation is an essential factor in the interaction between complex infrastructures and human behaviour. Because healthcare is intractable, clinicians are relied on to adjust to situations, for example emergency cases, to create safe outcomes, as well as recover from unexpected events. Reliability is a necessary requirement of safety and is concerned with the likelihood of occurrence of failure. Clinicians are vital to creating high reliability and a resilient system.

Through my research with obstetricians, I found that they successfully demonstrated their adaptive capabilities to respond to unforeseen, unpredictable and unexpected demands and recover from high-risk situations. The ability of obstetricians and their teams to be in a state of constant alertness, sensitive to changes in women’s conditions, continually re-evaluate their safety supposition, and respond as appropriate, is a key resilient strength that was evident. It also requires an organisational culture that nurtures a climate of trust and respect.

During interviews, obstetricians described the importance of trusting relationships, which fostered excellence in team working, and the ability to be collectively and consciously alert to risks and mitigations. Overall, they demonstrated excellent leadership attributes, valued safe care centred on the woman and her baby, good working relationships and the feeling that they made a positive difference.

"It was having the willingness to step in and take that level of responsibility in that situation. … it was also familiarity with the team and communication with the team, and drawing in the expertise of cardiologists and the anaesthetist so that we did have a cohesive joined up plan that we'd all agreed on and we'd communicated out to everyone."
Consultant Obstetrician, Manchester

“It’s about staying calm, understanding what the whole situation is, … it's about gaining the trust of the woman and the staff, gaining the trust of the staff is much easier if it's a team that you know, who you've worked closely with, who know you as well, because they know what your skill set is.”
Consultant Obstetrician, London

My research concluded that a systems approach to maternity safety including human factors and safety management must be adopted to understand 'work as done'. Safety can be improved through strengthening resilience as well as continuing to learn from the inevitable errors. I suggested using human reliability analysis, a technique looking at a process of care and systematically examining the process, to pinpoint and foresee possible failures so safety can be proactively managed within a unit.

Excitingly, the NHS Patient Safety Strategy (PDF), is striving to embed Safety-II principles, and healthcare regulators are considering how proactive safety management can be measured and developed as part of their inspection frameworks. Indicators for resilience engineering are also emerging which will help to assess a resilient work environment and provide metrics for safety measurement.  

In current RCOG work, systems thinking and Safety-II feature strongly. The Each Baby Counts Learn and Support Programme is drawing on safety-II principles alongside a behavioural change approach, and an explicit systems approach is being applied in the Avoiding Brain Injuries (ABC) Collaboration, exploring the use of Electronic Fetal Monitoring in collaboration with the THIS institute and Royal College of Midwives.