Can understanding context improve how we deliver training?

Tim Draycott is a Health Foundation Improvement Science Fellow, consultant senior lecturer in the School of Social and Community Medicine at the University of Bristol and a consultant obstetrician at Southmead Hospital in Bristol.

His team developed the ‘PROMPT Course in a Box’, a multi-professional obstetric training programme that has been adopted by 85% of UK obstetric units and is being rolled out across the world. We spoke to him about how a deeper understanding of context and the ‘active ingredients’ of effective training could transform outcomes for mothers and their babies.

What is PROMPT?

We initially developed PROMPT (Practical Obstetric Multi-Professional Training) to help improve care for women in labour at Southmead Hospital, particularly during emergencies. Maternity care across the UK is recognised to be mostly good but many women and babies still suffer preventable harm during emergencies in childbirth.

Care during labour (intrapartum care) demands sensitivity, clinical skill and acumen from a multi-professional team. Training needs to address all of these elements, so we used a really wide range of training techniques and tools when developing PROMPT, including some sophisticated simulation models. The result was a one day annual training course for all maternity unit staff. Everyone within the team takes part.

The training had a dramatic effect on our clinical outcomes, helping us to reduce intrapartum preventable harm to the lowest reported rates in the world. At Southmead we saw a 50% reduction in babies born starved of oxygen and a 70% reduction in babies born with a paralysed arm after getting stuck in the birth canal after the head is born.

As well as directly benefiting children and their families, this has also saved huge amounts of money for the NHS in litigation claims. In my own department we’ve seen this reduce from £25m in the decade before the training to just £3m in the decade since.

We developed the ‘Course in a Box’ (quite literally a box containing manuals and all the multimedia materials you need to run the course) so that PROMPT could be easily shared with other maternity units who wanted to use it. It has now been adopted by 85% of UK obstetric units, and is being rolled out across the world. 

Why do you think PROMPT has been so popular?

It’s cheap, simple and based on what Mary Dixon-Woods terms: the ‘practical wisdom’ of practitioners. It uses a bottom-up approach that obstetricians and midwives seem to understand and that works for them.

PROMPT aims to ‘make the right way the easiest way’, and uses tools to help practitioners do the right thing. What’s different about it is how it translates the latest clinical guidelines into practical exercises that address known problems. This means it can be used as a way for maternity units to ensure they are always working to the latest best practice.

And because care during labour is pretty similar across the world, the tools we’ve designed actually generalise pretty well – be it Australia, the UK, or a low resource setting like Zimbabwe.

As a Health Foundation Improvement Science Fellow you’re investigating the effects of context when implementing training. Why is this so interesting to you?

It’s funny because when we first designed the training back in 2000, we only really designed it for ourselves. Just like fish don’t see water, we didn't see our context because we were immersed in it.

Looking back, we were adapting for context – the training itself goes through a process of continual improvement using the latest guidelines and feedback from participants to refine content, so it’s not exactly the same course year on year. But it’s only when you try and generalise training so you can deliver it elsewhere that you become more aware of contextual issues that either facilitate or act as barriers.

So it’s in scaling up that context has really become important. The Improvement Science Fellowship has really enhanced my understanding of this while also introducing me to the breadth of skills and research needed to help us understand and grow PROMPT.

What are some of the main contextual issues you’ve encountered?

Certain factors really influence success, such as the size of the hospital unit or the strength of clinical leadership. There’s also something interesting about the intrinsic motivation of people and units who want to improve. Some units expect to have the best possible outcomes, while others just don’t seem to mind as much, or at least don't want to look at themselves so closely.

Funding and incentives are important. In England the NHS Litigation Authority incentivises training by discounting insurance premiums for units undertaking training, whereas in other areas of the UK there’s no such system. In Scotland there’s a country-wide roll out of PROMPT but local units are finding it hard to ensure staff are released for training without the indirect funding that English maternity units get through their insurance discounts.

Tell us more about the roll out in Scotland

All Scottish maternity units have agreed to participate in a stepped-wedge roll out of PROMPT (a robust methodological design meaning training will be rolled out in discrete steps to randomly allocated groups of units). This is a unique opportunity to investigate the impact of different contextual issues on a project implemented across a whole health system.

We’re hoping to get funding for a process evaluation which will run in parallel (called the Thistle study). This will give us a really deep understanding of what it is that makes our training work really well in some units, and less well in others.

What are the advantages of anticipating contextual issues in advance?

One useful analogy might be the difference between sowing seeds in different areas; they grow beautifully in fertile earth, but much less well in stony soil. In Victoria, Australia, there were subtly different results in eight maternity units after they introduced PROMPT. Units who trained the most staff appear to have had the most significant improvements whereas a significant minority of units struggled to train any staff and it is interesting that those units happened to be the ones with some of the worst clinical outcomes to begin with.

However, results from a simple survey of the culture and safety attitudes of staff from each unit seemed to correlate very well with how well units implemented training. So perhaps in the future we could use this tool to predict the fertile ground or stony soil. If we identified those less receptive units early on, we could do some preparatory work with them to help them improve.

What’s your long-term goal from a research perspective?

Two things. Firstly, we would like to contribute to improving maternity care to get the best possible outcomes for mothers and babies across the world and a deeper understanding of context will help us to improve the generalisability of PROMPT.  

Equally a better understanding of the active ingredients of PROMPT will help us broaden it out beyond maternity care. For example, we’ve already had good results testing the same techniques to improve outcomes for general surgery, so we know our approach is very broadly applicable. There’s potentially a much wider impact to improve care right across the NHS.