Bridging the Gap quality improvement initiatives are many and varied and are running simultaneously. Projects are co-designed by the partners using evidence to inform planning, with quality improvement activity implemented using the Plan-Do-Study-Act (PDSA) framework. PDSA is a pragmatic method for implementing and testing iterative changes through small rapid cycles of improvement with flexibility to adapt change according to feedback.
Bridging the Gap has developed on the premise that individual care providers are best enabled to provide quality care with knowledge, skills and systems in place that supports them to do so. We highlight several demonstration and quality improvement projects below.
Identified as a priority by Bridging the Gap partners in Melbourne’s south east, the Language in Labour project was designed by a multidisciplinary working group at Dandenong Hospital. The group comprising representatives from maternity, language services and MCRI adopted the Plan-Do-Study-Act (PDSA) framework to try out new ways to enable staff to be supported in offering all women with low English proficiency an accredited interpreter early in labour.
Four PDSA cycles over nine months in 2015 resulted in many learnings and achievements, including:
- the value of bringing together a group comprising managers and front-line staff from different hospital departments and working together to co-design options to address a service gap
- the benefit of using PDSA to build system and workforce capacity for change; strengthen the intervention; and support reflective practice
- identifying the need for professional development to enhance best practice in caring for women with low English proficiency and their families, and working with interpreters
- a significant increase in the proportion of women who required an interpreter having one in labour, as illustrated below.
Members of the working group and researchers have written a paper together reporting the Language in Labour project which has been published in the Australian Health Review. A Policy and Practice Brief summarises the learnings and achievements from the project Policy Practice Brief
The overall aim of Healthy Happy Beginnings is to improve the engagement of families of refugee background in pregnancy and early childhood care, improve health literacy and reduce social isolation.
Healthy Happy Beginnings is a community-based group pregnancy care model for refugee background women. It is a unique model as it is delivered by a multi-disciplinary team including a midwife, maternal and child health nurse, a community-matched bicultural worker and a professional interpreter, to provide clinical pregnancy care and improve health literacy in a community setting.
Community consultation with the Karen mothers and fathers informed the planning of the model of holistic pregnancy care and provided input for the name ‘Healthy Happy Beginnings’.
Healthy Happy Beginnings has been underway for two years with over 90 women attending to date.
Women find out about the program from the bicultural worker, GPs, Mercy Hospital, word of mouth from family and friends and other local agencies such as ISIS Primary Care. City of Wyndham, VicSEG New Futures, and Mercy Hospitals Victoria have formed a local partnership to deliver the program.
The objectives are to:
- Provide culturally appropriate care, centred on the woman and what she wants to know
- Provide community based care, close to home, enhancing access
- Be welcoming of women and her family and her community
- Identify complex obstetric and/or psychosocial needs earlier and respond appropriately with referral as necessary and follow-up
- Promote continuity of provider/s and consistency of information; ensure women are fully informed of choices and options
- Provide integrated pregnancy care that introduces and transitions women to the maternal and child health service and ongoing primary health care
- Build capacity of all staff to work with and care for families of refugee background in a collaborative and multi-disciplinary team
- Evaluate the program, including women’s and staff experiences and assess the financial sustainability of the model
To read about the launch of Healthy Happy Beginnings please click
Healthy Happy Beginnings has also been presented at the Victorian Maternal and Child Health Conference, profiled in a MCRI blog and will feature in publications of the partner organisations.
An evaluation with participants found that the program made women feel prepared, confident and reassured, with the greatest benefits coming from storytelling with peers, and developing trusting relationships with a team of professionals, with whom women were able to communicate in their own language. The role of the bicultural worker was considered pivitol in the multidisciplinary care team.
One mother reported:
‘I was a first-time mum, so I would come here and speak to the facilitators, and they gave me advice and just made me feel better…very reassuring and encouraging.’
The program has recently been awarded funding to expand the program to other sites and communties over the next 4 years. Funding was awarded by the Office for Multicultural Affairs and Citizinship through a Capacity Building and Participation Program - Strategic Partnerships grant.
At a day of professional development for City of Greater Dandenong MCH staff, gaps in the collection of demographic information such as country of birth and language spoken were highlighted. This hampers identification of women of refugee background for administrative purposes and may limit the tailoring of care to individual families; understanding a woman’s needs for interpreting services and their preferred language is an example here. Using the PDSA approach and starting small with just two MCH nurses at one centre, demographic information was checked for completeness and updated where missing or incorrect.
Results were monitored over time with learnings showing that:
- it didn’t take any extra time in the appointment to ask women where they were born, when they arrived in Australia and their preferred language
- the process of asking was straightforward and considered part of standard practice
- family members weren’t offended by the questioning; in fact this led to more open conversations
- sometimes it was difficult to remember to ask; electronic prompts weren’t mandatory
To replicate success and upscale learnings to another MCH centre, one participating MCH nurse was identified as a refugee ‘data champion’ and went on to share learnings, achievements and provide assistance to others
Identification of refugee background women to inform care and enhance referral pathways for maternity care
Women of refugee background, people seeking asylum and other vulnerable populations presenting for pregnancy care have been under-identified in health service administrative data and in clinical settings. This hampers the ability to inform care and enhance referral pathways that best meet the needs of these women. The Bridging the Gap partnership group in Melbourne’s west prioritised improving the identification of women who may be of refugee background by testing ways to improve administrative data sets and by improving the quality of general practitioner (GP) referrals to maternity. A working group formed to undertake service mapping of the current patient registration system, to identify the issues and complexities (e.g. multiple system interfaces) to streamline and enhance the patient registration processes and timely triage for the prioritisation to caseload midwifery care. More questions arose and a number of inter-related projects to improve identification were undertaken concurrently:
- Inclusion of four data items - Country of birth, Year of Arrival, Language spoken and Interpreter required – to provide a proxy measure for identifying people of refugee background in administrative data; this included understanding which data was captured in systems such as IPM (inpatient management) and the Birthing Outcome System.
- As a result of service mapping the patient registration and referral pathways and initial auditing of data in maternity referral forms at Sunshine Hospital, gaps in information provided via GP referral to the health service were found.
- Collaboration with a parallel project to improve the quality of referrals, provided opportunity for the four data items (listed above) to be included.
- Internal and external consultation undertaken by GP Liaison at Western Health along with professional development and newsletters supported general practice managers and GPs to improve referrals.
- Using the Plan Do Study Act (PDSA) framework proved invaluable in the various phases of improving the quality of referral data.
- A new position, triage midwife, enabled early identification of vulnerable women including those of refugee background, for triage to Midwifery Group Practice or Caseload midwifery. The model offers continuity of care from pregnancy, including birth and in the early days after birth and transition to maternal and child health.
- Maternity booking clerks (who receive and enter referral data) attended a professional development session on identification of asylum seeker and refugee background families, and continue to play an important role in enabling patient identification.