ACT Centenary Hospital for Women and Children – Maternity Model of Care and Demand Review

Leslie Arnott Donna Hartz Michael Nicholl

Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

Page |1 ACKNOWLEGEMENTS The reviewers wish to commend and thank all those who contributed to this review for their commitment, openness and frankness. The overwhelming willingness to share precious time and information ensured the review was conducted as efficiently as possible.

Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

Page |2 ADDRESS FOR CORRESPONDENCE Mr Ian Thompson – Deputy Director-General, Health Directorate Canberra Hospital and Health Services P.O. Box 11 WODEN ACT 2606

REVIEW TEAM MEMBERS AND REPORT AUTHORS Ms Leslie Arnott B Fine Arts, Postgraduate Diploma Business & Marketing Board Member Women’s Healthcare Australasia Acting Chair Childbirth Australia Dr Donna Hartz RN RM MMID Studies PhD FACM Post Doctoral Research Fellow University of Sydney Midwifery and Women’s Health Research Unit Royal Hospital for Women, Randwick A/Prof Michael Nicholl MB BS MBA (Pub Sec Mgt) PhD FRCOG FRANZCOG AFCHSM FAAQHC FAIM Vice-President Women’s Healthcare Australasia Clinical Director, Division Women’s Children’s and Family Health North Shore Ryde Health Service, RNS Hospital, St Leonards

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TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................... 4 Recommendations .........................................................................................................................5

INTRODUCTION ..................................................................................................................... 6 BACKGROUND ....................................................................................................................... 6 REVIEW OUTLINE ................................................................................................................... 9 Governance ...................................................................................................................................9 Terms of Reference ........................................................................................................................9

METHODOLOGY .................................................................................................................... 9 FINDINGS ............................................................................................................................ 10 Consistency of the model of care .................................................................................................. 10 Appropriateness of the model of care........................................................................................... 12 Impact of service demand on the operationalization of the model of care ..................................... 13 The impact of demand for clinical services .................................................................................... 15 Analysis of projected inpatient bed numbers ................................................................................ 17 Workforce demand related to maternity service delivery .............................................................. 18

APPENDICES ........................................................................................................................ 21 Appendix A: Schedule of meetings................................................................................................ 21

REFERENCES ........................................................................................................................ 23

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EXECUTIVE SUMMARY This maternity model of care and demand review of the Centenary Hospital for Women and Children (CHWC), hereafter termed the Review, was commissioned by the ACT Minister for Health, Ms Katy Gallagher, MLA. The purpose of the Review was to examine and provide an assessment of: 1) The Model of Care in the new Centenary Hospital for Women and Children (CHWC) Maternity Unit, and 2) The capacity of ACT Maternity services to meet current and future demand, taking into account recent changes to service demand as well as the model of care including commitment to expand capacity on the north side. The Review was prompted by the increased and unexpected demand since the opening of the new CHWC. The changes to the Medicare Safety Net in 2010 is temporally related to significant changes in the mix between private and public sector births with the number of public births increasing significantly over recent years. The increased number of public births occurred too late to inform the planning, design and construction of the new CHWC. The issues identified by this review include: 

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The Model of Care is well described with elements of the Model of Care well implemented. The CHWC is encouraged to continue with its implementation, paying particular attention to ensuring detailed change management and workforce plans exists for the ongoing implementation process. There has been limited adoption of this type of Model of Care in Australia, however it has been used widely in hospitals in New Zealand and the UK. There has been an increase in demand at Canberra Hospital, which was unexpected and not in line with the planning models. The facility has the capacity to deal with this demand, however as implementation of the Model of Care is ongoing and not fully implemented, the facility was unable to effectively manage this demand initially. Further, more detailed planning may have assisted in managing the demand and community expectations. Further work on implementation of the model of care, including ongoing change management plans would assist in ensuring requirements of the model of care are in line with the bed capacity of the hospital Analysis of the projected inpatient bed numbers for ACT Maternity Services on completion of Stage 2 of the CHWC reveals that the modelling is robust, however, the assumptions underpinning the modelling are ambitious (e.g. 85% occupancy & 5 year time frame to achieve the proposed Model of Care). To assist with the opening of Stage 2 and the ongoing implementation of the Model of Care, a more detailed and refined workforce plan for the CHWC would be beneficial.

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In summary, the proposed Model of Care for the new Centenary Hospital for Women and Children (CHWC) Maternity Unit that influenced the planning, design and build of the new unit, whilst innovative, was ambitious. The assumptions underpinning the model and the time-frame to achieve the model were optimistic. There is opportunity for more work to be done in relation to change management and workforce plans to further improve the links between organisational capacity and the physical built environment. It is noted that implementation has been compounded by the increased and unexpected demand since the opening of the new CHWC. The capacity of ACT Maternity services to meet current and future demand, taking into account recent changes to service demand and including commitment to expand capacity on the north side, seems appropriate. In response to the issues identified the Review Team makes 5 recommendations as detailed below. Recommendations 1. That the Model of Care continues to be implemented to ensure that the built capacity of TCH can be fully utilised. 2. That a new multidisciplinary Operational Commissioning Committee, including human resources and consumer representatives, be formed to guide the implementation of recommendations from this review. 3. Based on the lessons learnt from this review, a workforce plan for maternity services should be developed for Stage 2 and ongoing implementation of the models of care. Expansion of both the CaTCH program and Midcall service is thought to be feasible. The workforce plan needs to be inclusive of a progressive evaluation methodology. 4. That midwifery staff continue to be provided with educational and training pathways consistent with their full scope of practice in an acuity adaptable environment (LDRP rooms). 5. That the existing Birth Centre ‘space’ initially becomes the default area of care for all low risk women and that the area is equipped and staffed to accommodate postnatal stay. Further review is recommended for the entry and retention criteria for existing continuity models (CMP & CaTCH) with the view to ensuring that the birth centre space is maximised in an acuity adaptable environment (LDRP).

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INTRODUCTION This maternity model of care and demand review of the Centenary Hospital for Women and Children (CHWC) was commissioned by the ACT Minister for Health, Ms Katy Gallagher, MLA. The purpose of the Review was to examine and provide an assessment of the model of care in the new Centenary Hospital for Women and Children (CHWC) maternity unit, and the capacity of ACT maternity services to meet current and future demand.

BACKGROUND The vision for a Women’s and Children’s Centre of Excellence was first articulated during the development of the ACT Health Capital Asset Development Plan in 2006 which initially was developing a Procurement Feasibility Plan for a new Neonatal Intensive care Unit. The vision was translated into a conceptual design for a Women’s and Children’s Hospital on Canberra Hospital campus and a Final Feasibility Study report was issued in August 2008. The reports executive summary states: “Several key stakeholders from the region included the Executive team, senior representatives from ACT Health, TCH, Calvary HealthCare, Greater Southern Area Health Services, community health representatives, the ANU Medical School and Canberra based clinicians, all undertook to examine the models of care for maternity, gynaecology and paediatrics. This led to examination of many of the current practices and resulted in several key aspects being changed that were seen to be essential for TCH moving into the future. Of note was the idea to provide the same successful model of care that is provided in the Canberra Midwifery Program (CMP) in the general birthing unit of the hospital. This meant using Labour Birthing Recovery Postnatal (LDRP’s) rooms for the full continuum of care, allowing postnatal women to extend the occupancy time in the birthing unit to reduce fragmentation of service and avoid transfers between levels and rooms.” In section 3.2.2, The Proposed Model of Care, the report outlined the following assumptions:  85% of births will occur in an environment like a birthing centre  To support this, birthing facilities will be home like wherever possible  The CMP will be maintained as one of several models of care being offered to ACT women  Midwifery teams will operate in teams based on agreed parameters (which might for example be geographic locations) so as to support the continuity of care model  The model will need to be underpinned by a centralised intake system, provision of consistent information on model of care choices, assessment of risk status and focussed needs, implementation of staffing systems to promote access to a known midwife during birth for all women and maintenance of tertiary level services to ensure that

Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

Page |7 services can be provided for women with high risk pregnancies and more complex needs. Your health – our priority: ready for the future was announced by the ACT Government in the 2008-2009 year budget. This marked the beginning of a 10 year redevelopment of Health infrastructure in the ACT and funds were allocated for a number of initiatives including the Women’s & Children’s Hospital to be built on the Canberra Hospital site. The funding allocation was based on projections that the demand for health care would grow significantly over the following 10-15 years and therefore the capacity of the health system needed to increase. The priorities identified by the ACT Government were that services were to be:  Patient centred  Aligned with agreed priorities for the future  Safe and high quality  Equitable  Innovative  Integrated  Affordable  Flexible With respect to the new Women’s & Children’s Hospital, a state of the art facility was envisioned. To make a centre of excellence in a state of the art facility the projection of demand and research of best and innovative practices were to be combined with inclusive development of new models of care, interact with well-designed and practical spaces, be implemented by a flexible workforce in receipt of excellent preparation for a change in work practices and spaces, and be backed by research, training and teaching. In terms of Models of Care development for the CWCH a three step development process was proposed. Step One was undertaken in October 2008 and provided a preliminary model of care at a very high level. The purpose of Step One was to guide user group discussions and architectural direction. Step Two was completed in March 2009 and provided a lower level design of the Models of Care incorporating architectural design input, human resources (HR) input, information and communication technology (ICT) input together with the previous preliminary model of care information. The purpose of Step Two was to guide development of the schedule of accommodation, change management, HR and ICT strategies. The detailed Models of Care were developed using the input of staff (250), patients and carers (70) from all areas of the new hospital including the three user groups that had been established. A variety of techniques were utilised including interviews, focus groups, process mapping and root cause analyses, various data sources, patient and care stories, and ‘tagalongs’. The vision, values and priorities for the new Women and Children’s Hospital included:  Family centred care  Developmental care frameworks

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Continuity of care and carer Safe functional and comfortable physical environment Integrated and multidisciplinary care and treatment Provision of research and information resources for clinicians, primary care providers, patients and their carers Facilitation of innovation, research and translational research findings into practice, and Technology.

For women and babies the proposed Model of Care aimed to provide woman centred, holistic, evidenced based, culturally respectful, quality care for women in the ACT and surrounding area, a workplace that is satisfying, challenging and rewards excellence for its staff in a welcoming and safe environment. As a Centre of Excellence it was envisaged to provide a basis for excellence in teaching and research for the ACT and surrounding region. The primary principle of care was to provide woman-centred care which:  Included continuity of care provider(s) across the spectrum across a range of models of care offered  Recognised the woman’s right to self-determination in terms of choice, control and continuity of care from a known or known caregivers  Encompassed the needs of the woman’s family, her significant others and community, as identified and negotiated by the woman herself  Followed the woman across the interface between institutions and the community through all phases of her care, and  Is ‘holistic’ in terms of addressing the woman’s social, emotional, physical, psychological, spiritual and cultural needs and expectations. With respect to pathways in the patient care journey changes to process and care were identified across maternity, the birth centre, gynaecology and gynaecological oncology spanning antenatal, hospital and labour, transition of care, outpatient and inpatient care. Various methodologies were utilised to analyse the existing service and identify service gaps that needed to be addressed prior to the implementation of the new Model of Care. These included workflow analysis, patient perceptions, staff perceptions, and service relationships. Gaps were identified in: family-centred and developmental care frameworks; continuity of care across the spectrum; respect for self-determination with choice, control and continuity of care from known caregivers; encompassing the needs of the woman’s family, her significant others and community; the interface between institutions and the community; and, holistic care encompassing the woman’s social, emotional, physical, psychological, spiritual and cultural needs and expectations. Step 2 of the detailed Models of Care identified both people and process enablers for the new vision. Building and infrastructure implications were identified in broad terms. Step 3, the Model of care Operational Brief for CHWC Stage 1 of the Canberra Hospital redevelopment was published in July 2012. This document incorporated information pertaining

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Page |9 to role design, staffing profiles, ICT initiatives, implementation staging and clinical governance. Its purpose was to provide the service with a care model that can be operationalized within the clinical area. Step 3 detailed a project governance structure consisting of a Women’s & Children’s Executive Reference Group (W&C ERG) and a Women’s & Children’s Hospital Operational Commissioning Committee. The proposed clinical governance structure was to be unchanged. The building design and layout proposed a two staged implementation. Stage 1 was to be built onto the existing maternity building with relocation to the new facility in August 2012. Stage 2 relocation was proposed for August 2013. Stage 1 consisted of five dedicated blocks (Block A, B, C, D, & F of Building 11).

REVIEW OUTLINE Governance Terms of Reference The terms of reference for this review included:  Consistency of the Model of Care with evidence based, good clinical practice and with similar maternity services elsewhere in Australia;  Appropriateness of the Model of Care for the Centenary Hospital for Women and Children;  The impact of service demand on the operationalisation of the Model of Care in the Centenary Hospital for Women and Children;  The impact of the demand for clinical services provided by ACT Maternity Services on availability of inpatient beds and the impact on staffing of the service to manage throughput;  Analysis of the projected inpatient bed numbers for ACT Maternity Services on completion of Stage 2 of the Centenary Hospital for Women and Children; and  Workforce demand related to maternity service delivery.

METHODOLOGY The Review Team engaged with a wide variety of stakeholders as per the interview schedule (Appendix A). The Review was conducted in stages:  Documentation review  Interviews on-site at Canberra Hospital  Draft report preparation and submission for consideration and completeness against the review scope  Final review submission

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FINDINGS The Model of Care described in the Final Feasibility Study report issued in August 2008 which described that 85% of births will occur in an environment like a birthing centre (i.e. LDRP’s) is not articulated in the Preliminary Model of Care (Step 1), Detailed Model of Care (Step 2), or Operational Model of Care (Step 3) documents. In particular the detailed information pertaining to role design, staffing profiles and clinical service business rules that would underpin midwifery teams operating on agreed parameters, is absent from the planning documentation. The reviewers are of the opinion that the limited integration between the Model of Care described in the Final Feasibility Study report and its lack of articulation in the subsequent planning process, notwithstanding the changes in demand that have occurred, has led to important change management steps being overlooked with the operationalisation of the Model of Care being underprepared for the staged physical implementation. Consistency of the model of care The concept of patient care in the same room through to discharge irrespective of the level of patient acuity has evolved in general hospital care to reduce errors in communication, patient disorientation, dissatisfaction and falls (Bonuel & Cesario, 2013). In such models, specially equipped private rooms are staffed by nurses who have the skills and training to support the complete range of acuity of patients with similar conditions or disease processes. Such rooms are generally larger in size than regular hospital rooms in order to accommodate the patients changing needs as their condition changes, such as critical care equipment, additional staff, procedures and family members. Such rooms are described as acuity-adaptable rooms and have been demonstrated to reduce patient movement, decrease errors, minimise workflow bottlenecks, and enhance patient care. Inherent in such a model is that nursing competencies reflect critical care and acute care skills as well as discharge care, palliative care, or end-of-life care. Bonuel and Cesario, in their review of the literature with respect to the acuity-adaptable patient room, note that the available evidence indicates that the acuity-adaptable care delivery system is most effective if the patient population on a specific unit is homogenous and has predictable outcomes. According to Bonuel and Cesario, acuity-adaptable rooms have measurable outcomes in terms of lowering infection rates, improving patient safety, improving patient, family, and health care provider satisfaction, decreasing length of stay, promoting privacy, and improving care efficiency. The published literature on acuity-adaptable patient rooms is mostly descriptive and retrospective in design with few prospective and no randomised studies. The definition of an acuity-adaptable patient room is variable and there appears to be no standardised criteria. In the maternity context, LDRP’s are cited as an example of acuity-adaptable patient rooms. The literature suggests that the concept of acuity-adaptable patient rooms in maternity settings should be successful because of its homogeneous population; however, the variability in Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

P a g e | 11 occupancy rates and the potential lack of homogeneity in tertiary settings are potential threats to such a model. The literature is silent on the assessment of staff educational needs, competency of the caregivers and staffing ratios with such a model. Janssen et al sought to evaluate the nursing response to the introduction of single-room maternity care in the 1990’s by comparing satisfaction with the workplace environment among single room maternity care nurses before and after they worked in the setting and among nurses working in traditional birth settings (Janssen et al, 2001). Responses indicated that single-room maternity care nurses before and after working in the unit were significantly more satisfied with the physical setting, their ability to respond to patients’ needs, their opportunity for teaching families, the nursing practice environment, peer support, and their perceived level of competency. They also rated their satisfaction significantly higher than that of their colleagues in the traditional delivery and postpartum settings. Reports from the 1980’s and early 1990’s are mixed regarding staff satisfaction. The literature on staff satisfaction is limited by both the methodology employed and the small sample sizes. The Janssen et al paper is unable to separate the effect of the single room maternity care environment on satisfaction from the education program that prepared nurses to undertake care across the spectrum of maternity care. These authors highlight the need for an education program and improved competencies in single-room maternity care. Internationally, the Department of Defense (DoD) in the United States, issues space planning criteria for Military Health Facilities (DoD, 2013). This document recommends LDRP’s for all DoD facilities unless the average workload exceeds 1,200 births per year. For greater than 1,200 births per year the LDR model is recommended. This recommendation is based on the substantial savings in nursing and support personnel associated with fully cross-trained staff in lower volume units. Stichler, in her commentary on designing healthcare facilities states that the amount of space available, financial resources, and even the political clout of clinical leaders who may express an opinion without having information about the cost-benefits and pros and cons of each option ultimately affect the solution (Stichler, 2009) Specifically with respect to LDRP rooms, Stichler suggests that decision making should be influenced by the annual delivery volume, the size of the available footprint, and the organizational culture among other things. Changing the organizational culture from one model to another and cross training the nurses to ensure competency in all levels of care are highlighted as being particularly challenging. The reviewers are unaware of any similar tertiary service in Australia with widespread use of LDRP rooms. Centres with co-located birth centres utilise LDRP rooms as do stand-alone midwifery units and the reviewers are aware of the use of LDRP rooms throughout the United Kingdom and New Zealand. This is believed to be the first tertiary referral hospital in Australia to move to this particular Model of Care to such an extent. LDRP rooms were described in some detail within the Australasian Health Facility Guidelines in 2006; however, in Version 5.0 dated 12 April 2012, LDRP rooms are no longer included. This Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

P a g e | 12 latest version does, however, acknowledge that birthing rooms may be used in a flexible way to accommodate different service models and approaches with some used for the labour, birth and recovery phases with transfer to a post natal bed and others may also be used for the labour, birth and recovery phases, with the mother occupying the room until discharge (AHFG 2012). There is a lack of research evidence to support the proposed Model of Care. The published literature on acuity-adaptable patient rooms provides low level evidence only. The available evidence suggests benefits in terms of lowering infection rates, improving patient safety, improving patient, family, and health care provider satisfaction, decreasing length of stay, promoting privacy, and improving care efficiency. However, there is a paucity of evidence with respect to maternity services specifically. In terms of staff satisfaction with such models there is conflicting evidence. Critical success factors for such models appear to be volume, stable occupancy rates, homogeneity of the patient population, staff education and competency to work across the spectrum of maternity care. The ideals implicit in the Model of Care are important ones but for such a model to be efficient and effective a comprehensive implementation plan would be required. The experience of similar maternity services elsewhere in Australia is limited. The limited available evidence suggests the scope of the change and the timeframe for this project were ambitious. The reviewers were unable to identify an overall coherent, communicated and supported ‘roadmap’ for the service to achieve the proposed Model of Care in the timeframe of the project. Likewise the reviewers were unable to identify a change management strategy to support the spread of the proposed Model of Care. It was apparent to the reviewers that there was a lack of synergy between the planning process and the operationalisation of the proposed Model of Care. Appropriateness of the model of care Appropriateness of the proposed Model of Care was assessed using the criteria derived from the review of available literature. The assessment is presented in Table 1. Criterion Specially equipped private rooms Staff who have the skills and training to support the complete range of acuity of patients Homogeneous patient population

Stable volumes Predictable patient outcomes Stable occupancy rates

Evidence Detailed design demonstrates equipped LDRP rooms Assumed competency of midwifery workforce across the continuum of care Tertiary patient profile across spectrum of risk categories with evidence of increasing complexity Increased but stabilising volume Unpredictable patient outcomes Variable occupancy rates

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P a g e | 13 Volume <1,200 births / year Cultural readiness

Volume >1,200 births / year Uncertain

Table 1

Whilst the Model of Care proposed for CHWC is unlikely to be accessible to the majority of women in the short term it is important that the Model of Care continues to be implemented to ensure that the built capacity of TCH can be fully utilised.. Recommendation 1: That the Model of Care continues to be implemented to ensure that the built capacity of TCH can be fully utilised. Recommendation 2: That a new multidisciplinary Operational Commissioning Committee, including human resources and consumer representatives, be formed to guide the implementation of recommendations from this review. Impact of service demand on the operationalisation of the model of care The impact of service demand on the operationalisation of the MOC is not thought to be significant. There is the current perception held by various stakeholders (internal/external clinicians, community, and management) that an increased demand has contributed to current difficulties. The media has also played a part in enhancing this perception with further pressure from the opposition. From discussions with management, clinicians and consumers it was clear that a number of key components are necessary to support the 2-phased building development:        

A clearly articulated Project Plan Communication Plan Model-of-Care (MOC) Workforce Plan Milestone Plan Communication Tool (containing monthly progress) Mentoring system Practice Development Plan for Midwives Change Management Strategy

Less than optimal communication of the above elements has given the impression of a hospital unable to meet present and future demands. Although substantial work was previously undertaken to enhance and improve collaborative relationships amongst clinicians it is clear that more work is required.

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P a g e | 14 Strong leadership and mentorship is necessary to guide and slowly change the work ethic within clinical groups. Whilst there is established leadership for the Birth Centre and CaTCH program, further mentorship is required to ensure strong working relationships across all maternity care providers. A lack of consistency in practice guidelines can affect the provision of quality maternity care and efficient service throughput. Without compromising the care ‘ethos’ of the birth centre it is possible for the CaTCH program and birth suite to utilise the birth centre’s space during times of high volume usage, thus alleviating a perceived view of overcrowding in birth suite. Such change will require strong leadership to engender, over time, respectful and collaborative relationships amongst clinicians and by doing so, allow for a more flexible entry criteria to the birth centre to increase through flow. Consistent and agreed guidelines for referral and consultation will assist the process of transforming the maternity services area into a flexible working space. Consumer groups reported that they were largely left out of the planning process to the extent by which they were asked for input after the design phase had been completed. This too, created undue fear around the possibility of losing the birth centre ‘ethos’ of care. As a result, consumers fought for the right to have the birth centre retained as a separate part to the rest of the service. After discussions with consumer groups, it is clear that they are not interested in necessarily protecting the birth centre ‘space’, but moreover, interested in women with more complex needs having access to the same type of one-to-one midwifery care they have received. This further supports the idea of the birth centre ‘space’ as a more flexible working area to accommodate all women and their families. Consumers have noted that it is not the space that makes their birthing experience special or meaningful but rather the care they receive within the service. With this in mind, CHWC is well positioned to improve and enhance a closer working relationship with consumer groups interested in supporting the development of a woman centred/family centred approach to maternity care for women with varying clinical, cultural and socioeconomic needs. Others reported the desire to implement Midwifery Group Practices (MGP’S) but with some reticence around how GPs are likely to react. Although largely left out of the planning process GPs expressed a willingness to establish better communication with CHWC as well as the idea of establishing collaborative arrangements with midwifery group practices within the community. The development of such models would further alleviate perceived overcrowding within CHWC now and into the future. To support the demand for the expansion of one-to-one care models and MGP’s CHWC will need to increase its capacity for midwifery training and upskilling. Within CHWC there is a Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

P a g e | 15 perceived shortage of available experienced midwives and recently graduated midwives, both in the ACT and Australia-wide. Conversely, Queanbeyan provides for 3 midwifery training positions each year and reports that its service is often able to retain those midwifery students after graduation. This may be due in part, to more robust leadership and better working relationships amongst clinicians compared to those presently at CHWC. Whatever the reason, CHWC will need to invest financially and professionally in additional midwifery places to accommodate a growing desire for the expansion of MGPs. More training places are required, but as importantly, experienced mentors to help further training, support upskilling and develop collegiate relationships across all programs. Strong leadership is key to the success and longevity of this service. Over time increased demand on CHWC will require the service, as well as those in surrounding areas, to be flexible in their service usage and delivery. As an example, it is possible even now for gynaecological services (excluding surgery) to be taken over by Calvary. Clinicians and management from both facilities expressed a willingness for this to occur and agreed that it would assist the process in accommodating present and future demands on the service. It was reported that a change manager was employed, but left soon after without having provided guidance – written or otherwise – prior to their departure. Following this exit a replacement was not sought, but rather, existing staff were positioned to fulfil the role. This placement proved troublesome as it contributed to further erosion of clinical relationships and provided no meaningful support or guidance for the ongoing changes taking place within the service. When existing staff were charged with the responsibility of taking on change management (skilled or otherwise), their previous duties were not re-assigned. Thus the additional workload on those staff handling change management has been too great, further creating a perception of not enough staff available to meet service demand. Recommendation 3: Based on the lessons learnt from this review, a workforce plan for maternity services should be developed for Stage 2 and ongoing implementation of the models of care. Expansion of both the CaTCH program and Midcall service is thought to be feasible. The workforce plan needs to be inclusive of a progressive evaluation methodology. Recommendation 4: That midwifery staff continue to be provided with educational and training pathways consistent with their full scope of practice in an acuity adaptable environment (LDRP rooms). The impact of demand for clinical services There has been an increase in demand for clinical services with the feasibility modelling predicted birth rate for 2014 exceeded in 2012 and a continuing increase into 2013 that is likely to be close to the 2020 prediction of 3500. This has been attributed to a movement from the

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P a g e | 16 private sector and the attraction of the new maternity building at TCH. This increase is within the modelling and projections of required accommodation based on the scenario 5, the worst case scenario in the planning document. Whilst maternity care demand has not exceeded the peak expected birth rate of 3500 the birth rate has increased to near this level prior to there being the availability of full capacity of the new hospital. Currently there is a split maternity service with physical and cultural separation of available birthing spaces. This has resulted in a mismatch between demand for clinical services and current service models. There remains a higher demand than available service provision for the Birth Centre (BC) environment CMP model. The reported gap is approximately 200 women per annum. The new birth centre environment that was modified from the original plan now has 5 LBRP beds that are currently underutilised. Approximately 2.5 of these beds are utilised daily. The CMP cares for 650 women during labour and birth per annum and within the last year between 30-50% of these women gave birth in the Birth Suite (BS) or Operating Theatre (OT). The CaTCH program also accesses the birth centre for a small number of women utilising between 1-8 LBRP beds per month. The BC currently has strict low risk access and birth criteria. There is scope to increase utilisation of the BC environment by increasing the CaTCH program by 4-5 FTE midwives to reduce the waiting for the BC however this would only at best utilise another 0.30.5 LBRP bed per day. It was reported that many women do not know of the option to access the BC for care and birth or if they do may not consider it appropriate. This is due to restricted policies on levels of risk at booking and during pregnancy, obstetric interventions and pain management. They may also perceive that it is difficult to get on the list or waitlist. General Practitioners also reported that some of their women would access the birth centre environment but can’t under current service models. GP’s indicated that they would welcome shared care arrangements with the midwifery models of care that utilise the BC. Strategies and policies aimed at an increase in activity through the BC will relieve the current clinical congestion experienced in BS and Postnatal. There was a reported increase in high risk in flows but this was not quantified. Currently there is a 17% inflow rate of women of all risk. The review team were unable to make any comment on this. Calvary Hospital has until very recently had capped maternity bookings. The uncapping of bookings at Calvary Hospital will ease the current congestion at TCH and accommodate any further increase in births within the ACT. Calvary Hospital has also provided accommodation postnatally for some of TCH overflow. Women report very positive birthing experiences at Calvary Hospital and the hospital will be shortly introducing a continuity of midwifery care model for low risk women. Currently, with a 17% inflow (MOC expected 25%) and 28% CS rate the basic assumption of women could be cared for within the LBRP is unachievable. There are 15 postnatal beds. Based on current postnatal LOS of 2.5 days and with current patterns of caesarean section, high risk Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

P a g e | 17 pregnancy admission and women with other complication post birth, approximately 1575 women would require inpatient care. This equates to approximately 4725 bed days required per annum or 13 beds per day for this group. However, most women eligible for LBRP beds cannot access them at the current phase of the projects development. Once the new Birth Suite environment is fully operational this may be achievable. Consideration of a publicly funded home birth service (which is currently not supported by insurers) or the establishment a free standing birth centre have not been considered as alternate solutions at this stage. There is no reported increase in demand for Gynaecology services; however, there is scope to transfer some element of ambulatory Gynaecology to Calvary Hospital if required. Analysis of projected inpatient bed numbers The reviewers had an opportunity to speak with an ACT Health service planner, review the projected bed numbers across a number of scenarios and were provided with a copy of the Review of Inpatient Obstetric Projections for ACT Health by Hardes and Associates. In brief, the reviewers concur with the projected bed numbers and the findings of the Hardes and Associates analysis. The Executive summary of the Hardes and Associates Report is supported with acknowledgement that:     

The birth projections are broadly consistent with the historical population trends and hospital utilisation Maternity activity across the ACT public health sector has been relatively stable previously There has been a significant shift from the private health sector in the financial years 2010/2011 and 2011/2012 Length of stay trends in ACT public hospitals is in line with trends in other Australian jurisdictions There has been an increase in caesarean births in ACT public hospitals

Review of the previous projections reveals that ACT public hospitals will expect a modest increase in both vaginal births and caesarean births. Analysis of the projected inpatient bed numbers for ACT Maternity Services on completion of Stage 2 of the CHWC reveals that the modelling is robust, however, the assumptions underpinning the modelling were over ambitious (e.g. 85% occupancy & 5 year time frame to achieve the proposed Model of Care). It is recommended that a 75% occupancy rate should be applied to maternity services bed planning1.

1

Jones R. A simple guide to a complex problem – maternity bed occupancy. British Journal of Midwifery 20(5): 351-357. Available at http://www.hcaf.biz/2012/Maternity_Occ_Short.pdf

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P a g e | 18 Workforce demand related to maternity service delivery As stated previously there has been an increase in clinical activity close to the projected feasibility modelling expected in 2020. The workforce reconfiguration in line with the MOC has not been achieved and the MOC may need to be revisited in line with revised assumptions that have been discussed previously. The reviewers had the opportunity to discuss issues related to workforce demand with medical and midwifery managers and clinicians working in all models of care and clinical areas. The reviewers found that communication planning for decanting and commissioning based on the new facility configuration and the anticipated MOC could have been improved. The monitoring of workforce demand and impact on the workforce has not been clearly documented. There had previously been a coordinator to project manage the new configuration, however, it was reported that this person had left the service a considerable time ago and had left limited project legacy for the team to utilise. A dedicated project officer or project team to oversee the transition to the new facility is essential. There were no expressed deficits in the medical workforce. The CMP and CaTCH midwifery FTE are aligned to appropriate workloads of 40 women per FTE per midwife. The current midwifery Birth Suite workforce is adequate at the current level. There is an average of 6-7 birth per day requiring care by the Birth Suite midwifery and medical team which like all tertiary maternity services has peaks and troughs in daily activity. Antenatal care provision was not noted as having workforce issues. Postnatal midwifery workforce has been enhanced in early 2013 to approximately 23 FTE. This is adequate to staff the 15 bed postnatal ward however the postnatal staff have also been required to provide care in other clinical areas to accommodate an increase in postnatal occupancy. The postnatal overflow was not quantified. Similarly the antenatal/gynaecology ward is adequately staffed at approximately 17 FTE, however a variation in actual productive FTE by nearly 2 FTE reflects that activity or acuity of patients may have increased; however, this again was not quantified. There were mutual concerns expressed by both doctors and midwives about clinical collaboration deficits that currently exist between some medical officers and some of the midwives that work within the CMP program within the BC environment. The medical officers felt that they were excluded from knowledge of inpatient BC activity and that when complications arose for women during labour they were invited to consult at a later stage than they felt was clinically appropriate. Other concerns were with the level of clinical expertise for some of the midwives working within the BC environment. There was an expressed concern that while there was an expectation to have clinical faith in the midwifery clinical care within the BC, the medical officers were often called upon to undertake activities such as cannulation or perineal suturing that is within the scope of midwifery practice. Many midwives not working in the Continuity of Care models and the BC environment also had the skill deficits noted by the medical staff, however this was not expressed as a problem. In the new MOC (LBRP rooms) it is essential that all staff medical and midwifery are skilled and competent in their whole scope of practice as previously recommended.

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The MOC can be further enhanced by the extension of current strategies aimed at embedding and fostering collaborative relationships between clinical groups and clinical areas. Additional strategies could include dedicated obstetrician and a medical team to small midwifery group practices caring for CMP, CaTCH and Shared Care that undertake clinical meetings and case reviews. These teams could also promote more flexible management of women in the BC environment and may address the expressed professional differences that currently exist between clinical groups. The role clarity of midwives based on the ACM National Consultation and Referral Guidelines has previously been evaluated as an appropriate strategy at Ryde Hospital and the Royal Hospital for Women Randwick. The CMP has proven to be a very popular sustainable model of midwifery care. There are approximately 17 FTE CMP midwives caring for 650 women per annum for birth who are at low risk at time of admission for labour. There are also an unspecified number of women who are transferred out due to developing complication during pregnancy. There is a waitlist for women wanting to access the CMP. The CMC for CMP outlined the protection of the BC environment for women who are not only low risk but also adhere to the BC philosophy of natural birth, minimal intervention and non-medical pain management. This is not unusual for a BC and is usually based on a ‘guardian’ principle of reducing the real or perceived risk of obstetric intervention to women. Policies with more flexible entry and retention criteria will promote better utilisation of the BC. A policy of default admission for all low risk women to the BC could provide greater utilisation of the area. Two of the BC rooms could be made available for these women. A Birth Suite midwife could care for these women during labour and care for postnatal women in this environment. Strategies that promote the whole of scope of midwifery practice and clinical confidence should be implemented to facilitate this. In addition well women could be admitted and retained within the BC for post-dates induction, meconium liquor in labour or those requiring intermittent monitoring. Both clinical and consumer sentiment were positive that these initiatives were acceptable and achievable. Any Birth Suite midwifery enhancement of the BC environment would need to be accompanied by an expansion of the Midcall program to support a smoother transition to home. There is scope to increase the CaTCH model to accommodate the waitlist for the BC/CMP. However, midwifery management has reported that internal and external recruitment strategies have to date been unsuccessful. There is also an expressed reluctance for current midwives to work within the BC environment. Current educational strategies and professional development pathways need to be enhanced and clearly outlined to support all midwives in gaining confidence within their whole of scope practice. In addition, further team building activities may foster greater flexibility of the workforce within the birth environments. There is 22% CALD group at TCH and many families require considerable support. The community parent support programs are well utilised and appreciated by the new parent community. There has been no reference of the impact of the MOC on Community Services. Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review

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Recommendation 5: That the existing Birth Centre ‘space’ initially becomes the default area of care for all low risk women and that the area is equipped and staffed to accommodate postnatal stay. Further review is recommended for the entry and retention criteria for existing continuity models (CMP & CaTCH) with the view to ensuring that the birth centre space is maximised in an acuity adaptable environment (LDRP).

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APPENDICES Appendix A: Schedule of meetings Tuesday 28/05/13 Meeting of reviewers and WHA with Ms Elizabeth Chatham and Dr Steven Adair for briefing regarding project and tour of facility. Monday 01/07/13 Building 2 Level 3 (Mezzanine level, above reception, opposite Staff Cafeteria) Conference room 2 Start Time 08.30 9.00 9.30 10.00 10.15

10.45 11.15 11.45 12.15 12.30

13.00 13.45

14.15 14.45 15.00 15.30

16.00

End Time 9.00 9.30 10.00 10.15 10.45

11.15 11.45 12.15 12.30 13.00

13.45 14.15

14.45 15.00 15.30 16.00

Duration (min) 30 30 30 15 30

30 30 30 15 30

45 30

30 15 30 30

Personnel Ian Thompson Peggy Brown Jacinta George BREAK Senior midwives  Diana Wing  Nola Wong  Trudy Bergmann BREAK Deborah Davis Kerry Snell BREAK Junior Obstetrics and Gynaecology Doctors  Sarah Van der Wal  Lucy Bates  Kristi Bateman  Matthew Thompson BREAK Nursing and Midwifery  Liz Sharpe  Jeni Williams  Penny Maher Steven Adair BREAK Queanbeyan Hospital  Tania Dufty CMP & CaTCH  Melissa Pearce  Christine Fowler  Penny Maher Review Time

Role Deputy Director General – Health Directorate Director General – Health Directorate Health Services Planning Coffee Clinical Midwife Consultant – Birth Suite Registered Nurse and Midwife Clinical Midwife Consultant –Antenatal/Gynaecology Morning Tea Professor of Midwifery Consumer Representative Coffee

Senior Registrar Registrar Registrar Intern Lunch Director of Nursing A/g Director of Midwifery A/g Assistant Director of Nursing Clinical Director – Obstetrics & Gynaecology Afternoon Tea Director of Nursing and Midwifery - Queanbeyan Clinical Midwife Manager Outpatients Operations Manager Assistant Director of Nursing and Midwifery

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P a g e | 22 Tuesday 02/07/13 Building 2 Level 3 (Mezzanine level, above reception, opposite Staff Cafeteria) Conference room 2 Start Time 08.30 9.00

End Time 9.00 9.30

Duration (min) 30 30

9.30 9.45 10.15 10.30 11.00 11.45 12.15 12.30

9.45 10.15 10.30 11.00 11.45 12.15 12.30 13.00

15 30 15 30 45 30 15 30

13.00 13.45 14.15 14.30 15.00 16.00

17.00

13.45 14.15 14.30 15.00 16.00 17.00

45 30 15 30 60 60

Personnel Tanya Robertson Consultant Obstetricians  David Knight  Tween Low  Peter Scott  Trevini Nanda  Tobias Angstmann Travel New Mothers Group Travel Sue Byrnes Morning Tea Steven Adair BREAK Calvary Hospital  Christine Falez  Sim Hom Tam BREAK  Zsuzsoka Kecskes BREAK Rashmi Sharma Review Time Feedback  Ian Thompson  Liz Chatham  Steven Adair  Jeni Williams  Penny Maher Depart for airport

Role GP Advisor to TCH Director General – Health Directorate Deputy Clinical Director Obstetrics and Gynaecology Staff Specialist Obstetrics and Gynaecology Staff Specialist Obstetrics and Gynaecology Staff Specialist Obstetrics and Gynaecology Staff Specialist Obstetrics and Gynaecology New Mothers Group Phillip TCH Manager of Nursing Services Friends of the Birth Centre Clinical Director – Obstetrics & Gynaecology Coffee Director of Nursing and Midwifery – Calvary Clinical Director of Obstetrics and Gynaecology Lunch Clinical Director - Neonatology Afternoon Tea GP – Chair ACT Medicare Local

Deputy Director General – Health Directorate

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REFERENCES              

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   

Welcome to Women’s Healthcare Australasia Model of Care Review for Centenary Hospital for Women and Children GHD – Canberra. Report for Women’s & Children’s Hospital. Final Feasibility Study Report. August 2008 Excel Spreadsheet Maternity Workforce summary Jan 12- Mar 2013 Health Services Planning Documents: Bed summary, Planning Scenario summaries 1-5, Occupancy for Scenario %, & Bed scenarios Women’s Healthcare Australasia Benchmarking Maternity Care, The Canberra Hospital, ACT ACHS Gynaecology Clinical Indicator Achievement and Variance Report 2nd half 2012 ACHS Obstetric Clinical Indicator Achievement and Variance Report 2nd half 2012 Birth rate/ numbers: Delivery Suite; CMP; CatCH The evaluation of CatCH (Continuity of midwifery care at Canberra Hospital) Excel spreadsheet: Bed Count for current and planned capacity Bonuel N & Cesario S. (2013). Review of the literature: acuity-adaptable patient room. Crit Care Nurs Q, 36(2), 251-271 Janssen PA, Harris SJ, Soolsma J, Klein MC, Seymour LC. (2001). Single room maternity care: the nursing response. Birth, 28(3), 173-179 Stichler JF. (2009). Wicked problems in designing healthcare facilities. JONA, 39(10), 405-408 Department of Defense. (2013). DoD Space Planning Criteria Chapter 420: Labor and delivery / obstetric units. The Office of the Assistant Secretary of Defense Health Affairs. 17 January 2013. Available at http://www.wbdg.org/ccb/DOD/MHSSC/spaceplanning_healthfac_420.pdf . Accessed August 5, 2013. Australasian Health Facility Guidelines. 510 Maternity Unit. Available at http://www.healthfacilityguidelines.com.au/AusHFG_Documents/Guidelines/AusHFG% 20Part%20B%20Health%20Facility%20Briefing%20and%20Planning%20_%2000510%20 Maternity%20Unit.pdf. Accessed August 5, 2013 Australian College of Midwives. (2013). National Midwifery Guidelines for Consultation and Referral (Third ed.). Canberra: Australian College of Midwives. Beasley, S., Ford, N., Tracy, S. K., & Welsh, A. W. (2012). Collaboration in Maternity Care is achievable and practical. Aust N Z J Obstet Gynaecol. doi: 10.1111/ajo.12003 Tracy, S. K., Hartz, D. L., Nicholl, M., McCann, Y., & Latta, D. (2005). An integrated service network in maternity; the implementation of a midwifery-led unit. Australian Health Review, 29(3), 332-339. Hartz, D. L., White, J., Lainchbury, K. A., Gunn, H., Jarman, H., Welsh, A. W., Tracy, S. K. (2012). Australian maternity reform through clinical redesign. Aust Health Rev, 36(2), 169-175. doi: 10.1071/ah11012

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Jones R. A simple guide to a complex problem – maternity bed occupancy. British Journal of Midwifery 20(5): 351-357. Available at http://www.hcaf.biz/2012/Maternity_Occ_Short.pdf. Accessed August 30, 2013

Centenary Hospital for Women & Children – Maternity Model of Care & Demand Review