Co-designing maternity investigation systems: sharing the journey so far

In this session you’ll hear from the team working on one of the Q Exchange funded projects aimed at improving across system boundaries. 

You’ll hear more about their project: Co-designing maternity investigations systems using a Human Factors approach. They’ll share the findings from the data collection and analysis phase, providing an overview of the project’s journey so far. You will gain insights into the key challenges and successes encountered, and learn about the co-designed guide aimed at improving maternity services.

In 2017, Donna Ockenden led a review of maternity care at Shrewsbury and Telford NHS Trust, uncovering multiple failures in investigation practices and learning from past incidents. Similar issues were found in other reviews, such as Morecambe Bay, East Kent, and Nottingham. Key findings include persistent delays in governance, superficial investigations, and downgrading serious incidents to avoid scrutiny, compromising safety.

Despite some improvements, systemic issues in maternity services persist. The research project aims to address these by collaborating with local partners to co-design NHS trust governance practices using a Human Factors approach. 

Research Objectives:

• Appraise maternity governance and investigation processes using a Human Factors approach across three NHS Trusts
• Use findings to co-design a guide to support maternity services in improving governance systems
• Facilitate focus groups to assess the feasibility and acceptability of the guide
• Launch a guide to support maternity services in improving local responses to patient safety incidents

Study Phases:

• Phase One: explore maternity governance arrangements and investigation systems through interviews, observations, and reviews
• Phase Two: co-design recommendations and a guide with key stakeholders
• Phase Three: conduct focus groups to explore the guide’s feasibility, acceptability, and usability
• Phase Four: launch the co-designed guide to support maternity services

The study is underpinned by the SEIPS model, integrating human factors engineering and systems engineering to understand healthcare work systems and their impact on processes and outcomes.

Current Stage: Data collection and analysis will be complete by March 2025. The guide will be launched in July 2025, with ongoing efforts to secure funding for evaluating its long-term impact.

Impact: The project aims to reduce avoidable harm and death by improving investigatory practices and fostering a learning culture. The guide will standardise responses to patient safety incidents, creating safer and more efficient maternity care systems.

Q Exchange is our funding programme that offers up to £40,000 to member-led improvement projects in a collaborative process that draws on the knowledge of the community to refine, develop and vote on proposals.