Table 5

Recommendations and actions agreed to improve quality of hospital care

Domains of QMNCKey recommendations and actions agreed
Provision of care
Evidence-based practicesStaff training
  1. Organise regular high fidelity certified simulation training, with skills and drills and clinical case discussion, on the care of both newborn emergencies and low-risk newborn.

  2. Develop mechanisms to ensure that training is mandatory for all staff in charge of newborn care.

  3. Offer retraining course on a regular basis (every 6 months) to retain skills.

  4. Implement the regional course on breast feeding, (delivered according the problem-based learning methodology).

  5. Create a specific prescription system for formula milk: (a) only on medical prescription; (b) if on maternal request, undersigned by the mother; (c) monitor that all formula prescriptions by doctors are according to justified medical reasons.

  6. Mandatory course for all staff working in the delivery room on the immediate postpartum care (including skin-to-skin, etc).

  1. Regular meetings for each unit, every 4 months, for evaluating training needs, planning internal training and monitoring achievements.

  2. Annual planning for funding available for external training courses (including international events) with mandatory internal diffusion at hospital level of the content of the training.

  3. Develop a plan for resident’s training meetings (to occur biweekly).

  4. Train staff on the evidenced-based practices of low-risk pregnancy.

  5. In-service training and simulations to improve management of emotions, by health professional, during obstetric emergencies.

  1. Implementation of a monitoring system to assess and ensure health professionals’ skills and competence acquisition linked to continuous education.

  2. Protected time for training, with a more stringent application of the national legislation.

  3. Training of staff using the problem-based learning methodology.

Local protocols
  1. Create working group with protected time for protocols development and equal distribution of duties.

  2. Develop a protocol for the care of physiological pregnancy and define responsibilities by type of professionals.

  1. Internal inquire on existent protocols (content, date of last update).

  2. Definition of standards and mechanisms for the development and for the diffusion of protocols.

  3. Implementation of new methods for protocols diffusion (ie, use on clinical audits).

  1. Activation of research networks/studies on quality of maternal and neonatal care.

Actionable information systemsData collecting system
  1. Implement the use of the same patient information file in the obstetrics and neonatal wards.

  2. Define working group with dedicated time for monitoring data with quality improvement purposes (mixed professionals, for clinical units, epidemiology, directions).

  3. Maternal and neonatal mortality audits.

  4. Organise regular meetings to discuss statistics and their use for quality improvement.

  1. Review of existent databases and harmonisation among different databases.

  2. Regular structured meetings to discussion database findings.

Referral systemsContinuity of care
  1. Shared protocols with outpatient health services.

  2. Information folders and posters for mothers, developed in collaboration with antenatal outpatient services, to be diffused both a outpatient level (ie, antenatal courses), and inpatient level (US control, hospital website).

  3. Participation of hospital staff to the delivery of the antenatal training courses for mothers at outpatient level.

  1. Organise meetings, at least every 6 months, with personnel of the outpatient services to discuss key issues related to continuity of care.

  1. Implement regional network on high-risk pregnancies.

  2. Improve collaboration with outpatient care service on creating systems for emotional support of women.

Human resourcesAvailability of skilled professionals
  1. Rearrange distribution of human resources (doctors and nurses) within the hospital.

Supportive systems
  1. Periodic (every 3 months) appraisal with a supervisor to monitor the achievement of the professional goals.

  2. Regular meetings for discussing mechanism to ensure professional growth of staff and career development.

  1. Implementation of multiple communication strategies (face-to-face, email, poster, WhatsApp) to improve internal communication among professionals.

  2. Clear identification from each unit of specific quality improvement activities as goal for the budget of the incoming year.

Physical resourcesNDND
Experience of care
Effective communicationStaff training
  1. Training for all staff on counselling and communication.

  1. Define working group to develop strategies to improve effectiveness in professional communication.

  2. Training events and in-service training on strategies to overcome common communication gaps, within year 2018.

  3. Monitoring of effectiveness of the training with a before and after questionnaire for both service providers and users.

  4. Regular use of techniques such as staff filming to evaluate, discuss with a non-blaming attitude, the quality of communication.

See recommendations #12.
Supportive information to mothers
  1. See recommendations #8 and #9.

  2. Information video for mothers.

  3. Reactive guided visits for pregnant women to healthy newborn ward.

  4. Develop written information on newborn danger sign, to be distributed together with discharge letter and on the hospital website.Develop information folders for mothers, and checklists on the correct information for staff on high-risk conditions during pregnancies.

  1. Develop information folders for mothers, and checklists on the correct information for staff on high risk conditions during pregnancies.

  2. Organise, every 2 months, meetings with mothers to inform them regarding key procedure associated with emergency obstetric care (eg, informed consent for operative delivery, epidural analgesia).

  3. Organise weekly meetings open to pregnant women on key aspects of antenatal diagnosis.

  1. Development and diffusion of informative video for mothers and families (eg, antenatal care practices, labour and postpartum care) within year 2018.

Respect and dignity Staff training
See recommendations #11.See recommendations #15 to #18.
  1. Training of staff on women/patient rights.

  1. Curtain’s installation between beds on puerperium wards.

Emotional supportStaff training
See recommendations #6.See recommendations #5.See recommendations #3.
Other aspects of organisation of care
  1. Add a clinical psychologist in the neonatal team composition (from antenatal to postpartum care).

See recommendations #5.See recommendations #12:
  1. Collaboration with local peer-to-peer women’s support group.

Human resourcesSee recommendations #16.NDND
Physical resourcesGeneral comfort of wards
  1. Improve acoustic and illumination in the wards.

  • ND, not directly discussed; QMNC, quality of maternal and newborn care; US, ultrasound.