How data insights are improving access to antenatal care in western Sydney

Auburn Hospital Antenatal Service (AHAS) serves one of the fastest growing, most culturally and linguistically diverse local government areas in New South Wales. But last year just 4% of pregnant women were receiving antenatal care when they should.

As part of the Western Sydney Local Health District (WSLHD), AHAS was flagged within WSLHD’s Emergency Risk Management System in November 2018 as a result of this finding, leading to a change program — the Baby Steps project — to address the issues.

In a partnership between Auburn Hospital and the WSLHD Innovation and Redesign team, I worked alongside my project co-lead Auburn Hospital Clinical Midwifery Consultant, Helen Mou, and our project team to deliver the program. Part of the NSW Agency for Clinical Innovation (ACI)’s Centre for Healthcare Redesign Program, our primary project goals were to improve access to the service by 14-week gestation to at least 50%, to ensure we had the correct number of referrals being entered into the system, and to improve care transfer so that antenatal appointments could be better utilised by other women when care is no longer required.

We knew we needed to take action fast but methodically. Accessing antenatal care in the recommended timeframe before14 weeks’ gestation is critical to women receiving comprehensive care planning for their pregnancy along with diagnostic screening at key gestational milestones.

At their first booking-in appointment, women receive a very comprehensive check-up screening with a midwife who gathers information about their current pregnancy, previous pregnancies, births and psychosocial needs, so they can set them up with the right care.

Some women first present for care at the delivery of their child. When women do not receive the appropriate antenatal care, the likelihood of serious harm to the mother or baby increases.

WSLHD is committed to ensuring all the hospitals within its network meet or exceed required key performance indicators set by the NSW Ministry of Health and patient experience expectations.

Seeing through the eyes of our patients

Before starting the project, we needed to gain an understanding of why mothers in the catchment area were failing to show up to the antenatal service earlier in their pregnancy. Patient feedback gathered by bilingual health workers and consumers circulating in the outpatient waiting room became a crucial piece of the puzzle that helped us to get that patient lens.

The team used WSLHD’s patient feedback platform called My Experience Matters — which runs on Civica Experience — to collect the feedback needed for strategic planning. The standardised questions provided by Civica Experience allowed us to efficiently collect the patient feedback data, while the automated analytics report within 24 hours meant we could focus on other project activities and deadlines.

We captured emotional responses about the service, such as whether a patient felt delighted, loved, anger or frustration, and data heat maps identified areas for improvement. Key words commonly used in the comments section of the survey gave additional insights, including some pleasant surprises about patients’ perceptions of the service.

Since My Experience Matters is also used in other facilities within WSLHD to gather feedback across services, we could also benchmark against those areas. Benchmark comparison information is displayed like a traffic light system, with green representing above benchmark, amber not far off the benchmark and red below the expected service level.

Combined with other diagnostic interviews carried out by the team, including patient and staff interviews, as well as process mapping and data analysis, we were able to use this technology to quickly see what was holding back early participation in antenatal care.

Getting to the root of the problem

The process resulted in some key findings and identification of gaps in current processes, including:

• One in two women were being referred to the antenatal unit too late by their GPs.
• Once they were referred, they were having to wait around five to six weeks on average for their booking-in appointment — this left a bad taste in many mothers’ mouths, evidenced by the fact that we scored just 57/100 (well in the red on our benchmark of 85/100) on patient perceptions around the wait time for their first appointment.
• This was having a psychological impact, leaving women feeling anxious and worried.
   

On the plus side:

• Women were keen to have their pregnancy managed by AHAS.
• Once women started their care, they were generally very happy with the way they were treated and the quality of care received.
   

As a result of the data analysis, it became clear that GPs needed more information on the ideal time to refer women to the antenatal unit and the data they needed to provide so that the antenatal unit could efficiently triage women coming in. Sixty per cent of the referral letters the unit received from GPs were incomplete, leaving the unit without the necessary information to triage women promptly.

We hosted a GP education evening with our obstetricians, delivering educational sessions that would help build the partnership between the antenatal unit and the local doctors and improve the timeliness and quality of referrals. As a result of this — and the implementation of a referral screening and acceptance procedure where incomplete referrals were no longer accepted — we have seen the proportion of incomplete referrals fall from 60% to 17% in five months.

The feedback also highlighted the fact that the antenatal unit’s booking system needed attention. This led to a restructuring of the booking schedules. While this has yet to be implemented — as COVID-19 resulted in a switch from face-to-face to telephone consultations — this updated system will support better and more prompt care once the timing is right.

Another weakness that became clear through our research was that future appointments were not being cancelled after women had given birth and no longer needed care. Once addressed, we freed up almost 600 additional appointments in nine and a half months. This not only improved access to care for those who needed it, it also contributed to a 4% capacity increase and over $165,000 in additional revenue per annum.

Most importantly, with the change program now completed, we have been thrilled to achieve:

• An increase in the percentage of women starting antenatal care by 14 weeks gestation to 17%. This was primarily thanks to the introduction of a new triage procedure where women were prioritised with recommended timeframes to be seen and according to level of urgency — a relatively new practice within New South Wales. Although COVID-19 has presented us with new challenges, a rate of 50% is the future target.
• The largest proportion of women are now starting antenatal care between 14–18 weeks, an improvement on 18–22 weeks.
• The results of a post-implementation survey to assess progress on how the service is perceived by patients have also been very promising, with patient perception of waiting times rising to 81/100 from 57/100.
   

The Baby Steps program demonstrates that with the ready access to data insights that get to the heart of the problem, significant improvements can be made in health outcomes. While we still have further to go, our teams feel proud to be improving timely access to a safe, high-quality, woman-centred outpatient antenatal service for women in the WSLHD.

Image credit: ©stock.adobe.com/au/LOOKSLIKEPHOTO.COM