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Implementation, outcomes and achieving our aims


We are currently at the implementation stage, having completed the diagnostic and design phases of the programme. The implementation phase includes:

  • Putting 3 agreed interventions into place to improve the behavioural aspects of clinical escalation
  • Deliver any training required to teams to carry out the desired behaviours
  • Implement a baseline questionnaire with all staff prior to roll out
  • Repeat questionnaire following period of implementation (e.g. after 3 months)
  • Completing qualitative interviews/focus groups with selected staff to further explore the implementation of the intervention

We have designed a campaign called ‘IDENTIFY – COMMUNICATE - ACT’. This will be used as the platform for testing a bundle of change ideas. The change ideas will address the problems identified in several maternity safety reports, including the Each Baby Count reports and other recent reports such as the Ockenden report, together with the diagnostic phase of the programme.

The testing will help develop tools and techniques which can then be shared and disseminated across other maternity units in the country as part of an online learning forum still in the planning process.

Clinical escalation: success and outcomes

We hope to ensure that future clinical escalation goes from "good" to "great". If we succeed, our outcomes will look like this:

  • A reduction in unnecessary delays in the escalation process.
  • Improvement in response and action
  • Improvement In safety critical language
  • A psychological safe environment which helps staff to speak up without fearful repercussions.
  • Having the right level of information (succinct) to improve consistent sharing of information.
  • A reduction in the feelings around hierarchy
  • Embedding ways to thank staff and give positive feedback – showing respect and kindness.
  • Improvements in our listening and involvement of women.

Achieving our aims

At the end of the Each Baby Counts + Learn and support programme, we will have achieved our overarching aims by developing:

  • Interventions that will reduce harm to women and babies
  • Interventions that will helps staff work safely
  • Interventions that improve staff’s communication skills and ability to escalate
  • Implementation across 16 units to maximise learning and capture local context and local variability
  • Interventions that can spread across all units in England
  • Interventions that promote joy at work
  • Interventions that promote psychological safety and a culture of speaking up, reduce cultures of blame and incivility.