Methods
This was a prospective study that compared antenatal CHD detection rates by professionals (sonographers, radiologists, obstetricians) from 13 hospitals in Wales, before and after engaging in our ‘practical skills development programme’. The work was undertaken by the superintendent sonographer (NT) and fetal cardiologist (OU), both of whom were based at the University Hospital of Wales, with both representing ASW and WFCN. Collaborators included the ASW coordinator, charities, superintendent sonographers, ultrasonographer workforce, screening midwives, obstetricians and radiologists in all regional centres.
Setting the objectives
The project team aimed to deliver screening services (figure 1) that would improve patient outcomes by (1) Standardising regional care provision and screening protocols, including the adoption of outflow tract views as a mandatory screening protocol. (2) Using a teaching and practical skills dissemination programme to develop a workforce that is confident and competent in delivering these new protocols. The intended outcomes were (1) The provision of equitable access to fetal cardiac screening throughout South Wales. (2) Achieving more efficient use of National Health Service (NHS) resources. The timetable for achieving these goals was set at between 5 years and 7 years.
Figure 1Plan, Do, Study, Act (PDSA) cycle for the Welsh fetal cardiac quality improvement project. CARIS, Congenital Anomaly Register and Information Service; NICOR, National Institute for Cardiac Outcomes and Research.
Creating an inclusive team approach
All stakeholders (including sonographers, screening midwives, radiologists, fetal medicine specialists and obstetricians) were engaged to design and deliver a series of educational lectures and hands-on training activities. This process was led by the fetal cardiologist (OU) and key sonographers (NT, JK). ASW, the Welsh Health Specialist Services Commissioner, policy makers, hospital operational managers, patients and charities were consulted in order to create a more inclusive team and thus to affect a more sustainable programme.
Identifying root causes of the problem: training need analysis, patient and service user feedback
Root cause analysis was undertaken to identify potential barriers to the confidence and competency of sonographers. An All Wales training needs analysis (TNA) was undertaken in 2007 (ASW). This provided an opportunity for sonographer feedback on confidence and competence in fetal cardiac screening at the 20-week anomaly scan, which enabled identification of training needs and requirements.
One hundred and twenty-four sonographers from 12 hospitals were asked to complete a questionnaire (see online supplementary file S1). Eighty-one responses were received. One hundred and five patients were randomly interviewed and asked to complete a questionnaire (see online supplementary file S2). Eighty fetal cardiac service users (obstetricians and midwives) were contacted and 30 of them returned feedback questionnaire forms (see online supplementary file S3). These questionnaires have been repeated at regular intervals and local and national service development has occurred as a result of these responses.
Root causes of the problem were multiple, extending from human factors to issues with machinery and software; limited leadership and the lack of a professional support network; ineffective communication channels between the fetal cardiac specialist and sonographers; absence of structured teaching and training programmes; a lack of sonographer confidence; and absence of local cardiac lead support. Figure 2 is a generic Ishikawa diagram outlining potential factors that might have a negative impact on any anomaly screening programme.
Figure 2Ishikawa diagram showing potential causes of poor antenatal detection of congenital heart disease in any organisation.
In spite of enthusiasm among sonographers for improving anomaly screening capabilities there was limited knowledge of cardiac anomaly pattern recognition among practitioners. Most importantly there was a lack of expertise in obtaining and interpreting ‘outflow tract view’. There was disparity in service capability and excessively variable access to specialist opinion across the local centres within South Wales. Consequently, care was not standardised. These factors had resulted in inequality and a ‘postcode lottery’ for specialist advise on the diagnosis and treatment of congenital heart defects in the fetus. These results were discussed and recommendations were made for an All Wales fetal cardiac training programme to be undertaken (ASW, 2007).
Project measures
A set of outcome, process and balancing measures was defined and implemented, as outlined in figure 3. Outcome and process measures were defined with respect to improvements in individual sonographers’ skills, confidence and competency; true positive referral rates for each regional centre; the national (Welsh) detection rate of CHD; and clinical outcomes of selected cardiac abnormalities.
Figure 3Project measures were determined as above.
Balancing measures were addressed via semistructured and qualitative interviews with the local centre leads, screening sonographers, screening midwives and fetal medicine obstetricians, and via patient satisfaction surveys.
Team building and planning
A series of meetings were held with stakeholders (ASW) to discuss the severity of the problem and to agree on a structured training and teaching programme to achieve equivalent standards of care in all Welsh Hospitals. A core professional network (WFCN) was established, engaging all stakeholders (including patients, health boards, specialist services commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). Cardiac educational leads (midwife, superintendent sonographer, radiologist, obstetrician or a fetal medicine specialist) were then established in each hospital, specifications for a new cardiac anomaly screening protocol (‘outflow tract view’) were created and plans for training staff in the use of the new protocol were proposed.
Patient involvement
Patient involvement was extensive from the beginning of the process. Verbal and written patient feedback was gathered at various points of the programme. Patients were provided an opportunity to comment on all aspects of fetal cardiac screening including service delivery, counselling and communication as well as active participation in educational events.
Educational strategies and interventions
Dynamic and adaptive methods for teaching and delivering training programmes were devised to meet the needs of learners and overcome various barriers to their participation. Learning strategies included:
Regular visits to local hospitals for theoretical knowledge enhancement and for delivering hands-on training on real patients at routine screening clinics.
Ultrasound machine optimisation during practical hands-on training.
Evening workshops to review prerecorded video images of the most commonly overlooked abnormalities (as identified via clinical governance) and to deliver hands-on training on real volunteer patients.
Organisation of annual comprehensive national fetal echocardiography conferences.
Delivery of 6-monthly network continuing professional development meetings.
Additional structured training programmes delivered by ASW.
The provision of performance feedback letters to screening sonographers.
Dissemination of written guidelines, protocols and a sonographer’s handbook.
Supervised fetal cardiac scanning sessions at each cardiac centre.
Robust clinical governance in overlooked cases.
Regular audit and research activities.
Facilitating sonographer’s visit to fetal cardiology centre for further hands-on training.
Cost implications for ongoing training
All Wales educational interventions were funded by the Welsh Assembly Government. Other interventions were supported by programme leads as part of their professional activity and development. Trainer’s time for parallel activities was facilitated by charities and educational grants from various sources.
Project timeline, delivery of interventions and analyses
A project timeline was devised for the delivery of interventions, using a structured format with continuous phase and gate analyses (figure 4). A multidimensional approach was taken to improve service provision, including preparation of a comprehensive training package based on best practice guidelines; identifying and securing charity funds for continuing education; engaging ultrasound equipment manufacturers to optimise screening equipment and thereby enabling the best possible visualisation of fetal heart structures. Together, this culminated in the proposal of new protocols and their implementation by the ASW and district general hospitals. ASW commissioned a parallel training programme with a charity called Tiny Tickers.
Figure 4Project timeline and phase-gate analyses of the training programme outcomes. MDT, multidisciplinary team meetings. 3VT, three vessels and trachea.
Engaging policy makers to change screening protocols
Prior to 2010 only the four-chamber heart view was a mandatory component of the 20-week anomaly screening protocol in Wales; this view affords a reported antenatal identification of only 23% of cardiac abnormalities in the fetus.10 However, it has been widely accepted for many years that the addition of the ‘outflow tract view’ increases this rate substantially.9–14 Therefore there was a pressing need to change the existing anomaly screening policy by implementing the additional outflow tract view, with the intention of increasing the detection rates of heart defects and subsequently improving health outcomes.
Access to training opportunities
All institutions delivering the 20-week fetal anomaly screening were offered training days which were organised at the convenience of both the department and the trainer. The time spent in each institution was variable and largely dependent on the number of staff undertaking fetal anomaly screening. Individual institutions organised the staff that would attend the training sessions and a register of attendees was kept by both the institution and the trainer. During training days, each staff member had an opportunity to spend 1 day observing and scanning with the trainer. Interactive training was undertaken on the basis of a minimum number of examinations, so time was variable, although all staff undertook at least three detailed examinations with the trainer. There were inevitable instances of staff sickness or leave so if no subsequent training day was available at the institution, those that were absent were invited to attend a specialist fetal echocardiography clinic or, where possible, repeat sessions were organised.
Accountability, clinical governance, training need and outcomes
The lead fetal cardiologist, cardiac lead sonographers, superintendent sonographers, ASW and the screening workforce assumed shared accountability. Data were prospectively collected and outcomes were continuously analysed locally by the lead fetal cardiologist. The educational needs and practical skills of sonographers were evaluated by conducting repeated training-need analyses. Antenatal detection rates of CHD, centre-specific referral patterns, and perinatal mortality rates for selected cardiac anomalies were determined locally by annual audit, nationally by Congenital Anomaly Register and Information Service (CARIS) in Wales3 and by National Institute for Cardiac Outcomes and Research (NICOR)4 in the UK. The implemented protocol changes were reinforced by active participation of the stakeholders. This was achieved via ongoing training and by dissemination of audit results and practice analyses.