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On average it takes 17 years for an evidence-based recommendation to achieve full clinical uptake. The RCOG and the Each Baby Counts team are committed to seeing recommendations from reports implemented into practice as soon as possible.


There are challenges in implementing recommendations, including resource implications, cultural resistance from staff, trusts or commissioning groups, and barriers from demographic differences. The RCOG considered the type of recommendations available and the challenges they posed.


Designing recommendations

Behavioural change elements

These are medium cost, very hard to implement, good at effecting lasting change, such as the human factors education and simulation package.


Changing our behaviours and optimising the way we work as a team sounds easy. However, in order to change how we behave at work, we need to have the correct culture in place. This work is in its infancy in maternity, being led by NHS Improvement’s Maternity and Neonatal Health Safety Collaborative. Once the culture is correct, senior leaders need to role-model, consistently, the changes they want to see. Human factors and team-working will only improve if those leading the team work consistently towards a clear goal. These packages are hard to implement, because training is needed followed by a measured period of reinforcement of desired behaviours.

Structural elements

These are high cost, easy to implement, good at effecting lasting change, such as  risk assessment tools (electronic) for women coming on to the labour ward.


Elements of a system that use forcing measures to change care pathways are very effective at making changes. For example, if you wanted to make absolutely sure that no women came on to the delivery suite without a risk assessment, you could create a piece of software to complete the risk assessment and make it generate a code which is then required to open the door to the delivery suite. This is an extreme example, and would have obvious safety implications, but demonstrates the principle of how a structural element can be effective at making change. Practical examples of this in health care include blood fridges that do not unlock until you scan a patient’s wristband. These elements are costly to design, but once made are easy to implement and effect lasting change.

Educational elements

These are low cost, easy to implement, poor at effecting lasting change such as attending a CTG course.


The power of education to effect changes to patient care is greatest in under-developed healthcare systems. In a system like the NHS, the reason for good care not being delivered is rarely that the staff involved were untrained or didn’t know what to do; it is more likely that the right thing to do was not available or not easy. Courses and conferences are poor at changing physicians’ behaviours2 and improving practice, but cost very little and are likely to be better than doing nothing at all.


Prioritising recommendations

At the Each Baby Counts Clinical Engagement Forum (June 2017) we ran an interactive session during which the audience (predominantly midwives and obstetricians who are Each Baby Counts Lead Reporters) responded to questions in real time using their smartphones. Three hundred delegates attended, of whom 103 registered to take part in the interactive session; there may be some bias towards attendees who owned smartphones and were willing to register, but this represents a reasonably representative sample of those who were at the meeting.


The first question we asked was ‘Which of the recommendations in the report are most important to you?’ 73 delegates answered this question, representing 71% of those who registered for the interactive session. The responses are as follows:



A senior member of staff must maintain oversight of the activity on the delivery suite, especially when others are engaged in complex technical tasks.


All members of the clinical team working on the delivery suite need to understand the key principles of maintaining situational awareness to ensure the safe management of complex clinical situations.


Key management decisions should not be based on CTG interpretation alone.


Women who are apparently at low risk should have a formal fetal risk assessment on admission in labour irrespective of the place of birth to determine the most appropriate fetal monitoring method.


When managing a complex or unusual situation involving the transfer of care or multiple specialties, conduct a ‘safety huddle’ – a structured briefing for the leaders of key clinical teams.


The paediatric/neonatal team must be informed of pertinent risk factors for a compromised baby in a timely and consistent manner.


Staff tasked with CTG interpretation must have documented evidence of annual training.


NICE guidance on when to switch from intermittent auscultation to continuous CTG monitoring should be followed. This requires regular reassessment of risk during labour.


Decision making is more difficult when staff feel stressed and/or tired. A different perspective improves the chances of making a safe decision.


If therapeutic hypothermia is being considered, continuous monitoring of core temperature must be undertaken. Early efforts to passively cool the baby should also be considered (turn off the heater, take off the hat).


The two top-ranked recommendations were the human factors recommendations relating to oversight of activity on the delivery suite and understanding situational awareness.


Selecting implementation tools

We then asked the attendees what implementation tools they would most like to help them in their units. Those relevant to human factors included:

  • Training scenarios
  • Culture shift
  • Human factors training specific to maternity and birth centre.
  • Triggers that midwives/junior doctors can use to insist that the Consultant is present
  • Checklist
  • Training video
  • Human factors training package/presentation
  • Human factor training
  • Other unit’s experience as an example
  • Collated learning from human factor issues


Implementation ‘mini-toolkit’

Based on the feedback we received and the need to make an implementation toolkit that was as close to cost-neutral as possible for trusts and health boards to use, we decided to develop a ‘mini-toolkit’ for situational awareness. 
It should have no resource implication for maternity providers to implement.


In collaboration with the Norfolk and Norwich University Hospitals NHS Foundation Trust and Atrainability (a human factors consulting firm), we created a mini-toolkit consisting of three elements, aimed at supporting implementation of the human factors recommendations about maintaining a helicopter view and situational awareness. This is a complex educational intervention that aims to change behaviours by reinforcing the video learning with simulation.

Learn more about the Improving human factors toolkit here