Towards a multidimensional approach to measure quality and safety of care in maternity units in Oman

Abstract

Improving the quality and safety of maternity services is an international top agenda item. This thesis describes the progress towards the development of a multidimensional approach to measure the quality and safety of care in ten maternity units in Oman based on three of the five dimensional Patient Safety Measurement and Monitoring Framework (PSMMF) which include measuring "past harm" and "anticipation and preparedness”. The three monitoring approaches used in this research are: (1) measuring the patient safety culture (2) measuring patient satisfaction (3) and monitoring caesarean section rates. The specific objectives of the research are to (1) measure patient safety culture level, (2) examine the association between nurse’s nationality and patient safety culture, (3) validate an Arabic language survey to measure maternal satisfaction about the childbearing experience, (4) measure patient satisfaction about the childbearing experience, and (5) to examine caesarean section rates across maternity units using statistical process control charts. This thesis started with four systematic reviews that focused on (1) the use of patient safety culture for monitoring maternity units (2) the available interventions to improve patient safety culture (3) Arabic surveys available for measuring maternal satisfaction and (4) the use of statistical process control charts for monitoring performance indicators. The overall conclusion from these reviews that these approaches are being increasingly used in maternity, found feasible and useful, and there are areas that need attention for future work. Five field studies were conducted to address the research aim and objectives. Patient safety culture was measured by a cross-sectional survey of all staff in the ten maternity units. It was found that safety culture in Oman is below the target level and that there is wide variation in the safety scores across hospitals and across different categories of staff. Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses in all domains except in respect of stress recognition and this difference need further investigation and needs to be considered by designers of interventions to enhance patient safety culture. Using two existing validated English surveys, an Arabic survey was developed, validated, and used to measure maternal satisfaction with childbirth services. It was found that the new survey has good psychometric properties and that in all the ten hospitals, mothers were satisfied with the care provided during child delivery but satisfaction score varied across hospitals and groups of participants. Caesarean section rate in the last 17 years was examined using statistical process control charts to understand the variation across the ten hospitals. It was found that caesarean section rate is above the rate recommended by the World Health Organisation. Special cause variations were detected that warrant further investigation. In conclusion, the field studies demonstrated that it is feasible to use the three approaches to monitor quality and safety in maternity units. However, further work is required to use these data to enhance the quality and safety of care. Additionally, future work is needed to cover the other three dimensions of the PSMMF.