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Improving maternity care in Victoria: An accidental learning healthcare system

With the aim of delivering higher quality and safer care for all patients, the learning healthcare system has been proposed as a valuable structural reform to healthcare. It is built on the idea that rapid learning and timely application of that knowledge can improve the efficiency and effectiveness of care, and ultimately lead to better outcomes.1,2 There are very few examples of atscale learning healthcare systems in Australia. Here, we explore whether progressive changes to Victorian maternity services have ‘accidentally’ delivered a learning system that is poised for formalising. Victorian obstetric practice has a long and proud tradition of reporting outcomes for the purposes of quality improvement. That foundation was first formally laid by Dr Robert Marshall Allan in 1928. Allan led an inquiry, commissioned because of quality and safety concerns, into the state’s obstetric outcomes. He found that many of the healthcare problems in Victoria in the 1920s were because ‘there [was] no central authority controlling the health affairs of the State’.3 Allan’s vision for maternity care was to develop a system that was continually learning, governed by central oversight, anchored by performance reporting, and championed by clinicians. In Victoria, Allan’s work was the forerunner of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM), established in 1962. For nearly 60 years CCOPMM has published state-wide reports of obstetric outcomes. The annual reports enabled regular expert overview of state-wide pregnancy and neonatal outcomes with the ability to track and report trends over time. However, annual reporting of outcomes has not seen improvement at either a scale or pace that we might hope for. This may be due, in part, to the necessarily retrospective and somewhat time-lagged nature of CCOPMM reporting. Such state-wide outcome reporting also considers the system as a whole, obscuring variation between hospitals. Improvement then becomes wholly dependent on individual services being able to identify their own priorities and locally implement improvement initiatives. This decentralised approach lacks the central oversight called out by Allan,3 and more recently by Duckett following the events in Bacchus Marsh,4 and does not have the integration required of a learning healthcare system that enables the continuous improvement intended by both. So is Victoria’s maternity system sufficiently positioned to become a learning healthcare system, should it choose to? At its core, a learning healthcare system has three fundamental elements – timely transparent data reporting, good communication that enables shared learning, and collaborative participation for improvement by all stakeholders including consumers. The intent is to seamlessly identify, respond to, and correct unwarranted variation through a continuous feedback loop of care provision, outcome reporting, reflection, research, and timely application of better practices. Implicit to the entire system is an aim, preferably a measurable one.5 Achieving measurable goals, irrespective of the goals themselves, relies on data. Routine capture and reporting of clinical data identifies the targets for improvement and informs progress toward the aim. This works best when performance data are reported as a collection of outcome, process, and balancing measures. The combination of reporting all three types of measures provides a panoptic view of care delivery, maximising the use of data to inform improvement. That is why, for nearly 20 years, the Victorian state government has supplemented the CCOPMM reports with the annual Perinatal Services Performance Indicators (PSPI) report, which provides comparative clinical performance data by individual hospitals, both public and private, on over 20 outcome and process indicators.6 The report has enabled more granular level reporting that identifies variation between services, makes performance publicly visible, and permits benchmarking. Hospitals are further identified by name, which leverages the innate desire of clinicians and services to improve.7 The indicators reported in the PSPI span across antenatal, perinatal, and postnatal care, but in their current form are measures of process and outcome only. Communicating hospital performance data publicly with the intent of driving improvement is evidence-based8 and widely practised. New Zealand, Denmark, Ireland, and the United States all report obstetric outcomes at the hospital level. However, these reports, including the Victorian PSPI, are less timely and more remote from the care provider than required of a learning healthcare system. One solution to this is to make the reporting of performance data more readily accessible to frontline clinicians with near real-time reporting. In the United Kingdom and Canada, maternity ‘dashboards’ have been integrated into clinical practice, making visible comparative performance against evidence-based goals, with signals to alert underperformance. This type of clinically meaningful, near-real-time feedback has been effective,9 and has encouraged maternity dashboards being introduced in Victorian public maternity services in 2018, reducing the time lag Aust N Z J Obstet Gynaecol 2021; 61: 165–168