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Maternity and Neonatal Safety Improvement Programme

If you would like to find out more about work and resources in the West of England related to maternal and neonatal safety during COVID-19, please visit our dedicated webpages

The Maternity and Neonatal Safety Improvement Programme (MatNeoSIP), was renamed following the launch of the NHS Patient Safety Strategy in July 2019. It was previously known as the Maternal and Neonatal Health Safety Collaborative. For more information visit NHS Improvement’s page on the collaborative.

About the Collaborative

Locally, we are working in partnership with our Local Maternity Systems (LMS) and other partners including:

Download maps of our local learning system region which covers the West of England and Somerset.

The South West Clinical Maternity Network have produced very helpful frequently asked questions on Local Learning Systems.

The Approach

We aim to:

  • improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England
  • contribute to the national ambition, set out in Better Births of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020.

You can click the icons below to ‘jump’ to that section of the web page, or scroll down for each topic alongside additional information:

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Watch this video produced by the South West Neonatal Operational Delivery Network: A guide for parents on what to expect when on a neonatal unit

Previous events (and resources)

  • October 2020, a virtual West of England Learning System 9 Event, access 5ALtC^95
  • July 2020 – MatNeo Safety Improvement Network webinar. You can watch a recording here
  • March 9 2020  — National Learning and Sharing event, Manchester
  • November 2019 — National Learning Set 3, Guidebook  access W3LS3
  • October 2019  — Local Learning System 5, Bristol, Slides and worksheets on reliability
  • July 2019 — National Learning Set 1. Guidebook access W3LS2
  • May 22 2019 — Local Learning System 4, Bristol. Slides
  • May 8 2019 — National Learning Set 1. Guidebook access W3LS1
  • May 8-10 2019, Wave 1 Learning Set 1 (Bristol). Guidebook access W3LS1.
  • March 25 2019  — Launch event in London.
  • February 2019, Local Learning Set 3 (Bristol). Slides
  • January 16-18 2019, Wave 3 Learning Set 3 (Bristol). Guidebook access W2LS3.
  • October 10 2018, Local Learning System 2 (Bristol). Slides
  • September 11-13 2018, Wave 2 Learning Set 2. (London). Guidebook access W2LS2.
  • July 3 2018, Local Learning System 1 (Bristol). Slides and Output report
  • May 9-11 2018, Wave 2 Learning Set 1 (Manchester). Guidebook access MN18
  • March 1 2018, National Sharing Day. Plenary presentation

Read more about driver diagrams in our QI toolkit

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What is Quality Improvement?

Watch and Read
Introduction to Quality Improvement Training
At the Learning level the subject may be new to you. You will gain an understanding of the subject and know where it fits within the improvement process. You do not have to have developed competency in all areas before you move onto the next level. It is important to be aware that you could be at the Learn level in one subject, such as Measurement, but in the subject of Using PDSAs you may be at the Lead level.
Watch and share this video from Dr Mike Evans on QI in healthcare.
Read one of Sonia Sparkles’s sketchnotes in particular her excellent illustrated guide to QI produced with East London NHS Foundation Trust.
Watch Human Factors: A Quick Guide.
Online training through the Improvement Academy Bronze QI training
Attend an “Anyone for tennis? Introduction to QI” workshop
Improvement Academy: Human Factors Bronze level
Applying your Quality Improvement knowledge in practice
At the Living level you will be starting to apply your knowledge and will be on the road to developing your skills in practice. You may find that you feel your confidence and skills transitioning from being a novice user of the skills progress you to becoming a confident implementer. You will be using the knowledge and skills in your improvement work alongside others in the project team or independently. You will be aiming to feel that you are “living” the skills in your day to day improvement work.
Watch an introduction to Quality Improvement in 4 objects — a Russian Doll, a lamp, a tally sheet, and scales and then read the supporting blog post.
Access the MINDSET QI toolkit at
Read our Guide to Quality Improvement: a handy, A5 sized handbook, which explains what QI science is all about and how it can be used to deliver safer and better patient care
Apply for the Q network at
Hard copy run chart poster from 1000 lives wales.
NHS Scotland Culture safety discussion cards
Online training through Improvement Fundamentals
1.       Quality improvement theory
2.       Quality improvement tools
3.       Measuring for quality improvement
4.       Spreading quality improvement
Access IHI Open School (contact your improvement lead for password)
Join NHS Horizons School for Change Agents.
Leading yourself and others in quality improvement
At the Leading level you will be confident that you are able to lead yourself and others in the implementation of a subject area. It may be that you lead a new improvement team through the exercise of writing a driver diagram. You do not need to be a leader in your job role to be a leader of QI – anybody in the improvement team can progress through the competency levels of the 3 Ls and become a Leader.
Watch Bill Lucas talk on the Habits of an Improver
Read Plot the Dots guide and access resources.
Watch videos at  The Little Voice Inside
Wessex AHSN’s keys to positive practice
Online training through Future Learn Quality Improvement in Healthcare
Online training through the Edward Jenner programme
Host your own “Anyone for tennis?” session with a team

Developed based on the 3Ls model initiated by the South of England Mental Health Quality and Patient Safety Improvement Collaborative

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Useful resources

Read and share resources shared through national and local learning sets:

Smoke-free pregnancy resources

The Smoking in Pregnancy Challenge Group have a number of useful resources including

  • A briefing on the use of incentive schemes to support pregnant women to quit smoking. The briefing should support the commissioning of incentive schemes and give both commissioners and practitioners a set of ‘lessons for practice’ to consider before launching such schemes: download here.
  • Updated resources on the use of e-cigarettes in pregnancy:
    • An updated guide for maternity and other healthcare professionals, including a summary of the evidence on e-cigarettes and suggested responses to some frequently asked questions: download here.
    • A short key messages document for health professionals working with pregnant women and their babies: download here.
  • An updated infographic for pregnant women: download here.

They have also recently set up a network of Smokefree Pregnancy Champions to bring together individuals from maternity settings who have responsibility for implementing national guidance on smoking in pregnancy to share practice and learning, receive regular updates on new research, policy development and resources, and feed into national discussions on supporting local areas to reduce SATOD rates.

A guide to being a Smokefree Pregnancy Champion can be found here along with an introductory letter from our Challenge Group Co-Chairs and the National Smokefree Pregnancy Champions, Jacqueline Dunkley-Bent and Viv Bennett.

Deteriorating patient resources

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Safety Culture and Leadership

As part of the programme, trusts carry out a survey on their safety, culture and leadership. Some resources to support the debriefing process.

Image from the Awkward Yeti


Culture simply means ‘the way we doing things around here’. It’s a way of quantifying what it feels like to come to work. A good culture usually means that people enjoy coming to work and feel like a valued member of the team. It’s not about what you do but the way in which you do it in terms of the interactions between people in a unit, team or department.

A good culture cannot be provided by leaders, although they do have a part to play. Culture is local and each member of the team needs to understand their role in supporting and contributing to a positive culture and work environment for everyone, every day. Leaders must drive the culture change by demonstrating their own commitment to safety culture and providing the resources to achieve a culture of safety.

Read the Just Culture guide from NHS Improvement.

Start a conversation about culture with a colleague. If you need a guide to start the conversation check out Tools to Talk video

Watch Safety Differently: the Movie” a 30-minute documentary telling the story of three organisations that changed their safety culture.

Read Wessex AHSN’s keys to positive practice.

Watch this animation which shows the Circle of Care – a framework to help healthcare professionals think about, practice and demonstrate high-quality compassionate healthcare. This framework re-envisions compassionate healthcare by placing it in a broad social and interpersonal context, describing a multi-directional flow of care between healthcare professionals and their colleagues, patients and carers. Crucially, healthcare professionals must also care for themselves. Circle of Care was created as a result of a collaboration between the Simulation and Interactive Learning Centre (SaIL) at Guy’s and St Thomas’ NHS Foundation Trust (GSTT), and Clod Ensemble’s Performing Medicine programme.



Read about the connection between work-life balance and safety in this article by James Reason: three buckets model.

Watch Visit for infographics to share with your team.

Read about Learning from excellence — an approach developed based on appreciative inquiry to look at where things go right. Read their quick start-up guide


Read Safer Healthcare: Strategies for the Real World — this is a free e-book from Professor Charles Vincent and Dr René Amalberti.

Say thank you to a member of your team who has helped you today.

Watch this short video on How to HuddleSafety huddles are part of a systematic approach to reducing harm. Find out more.

Print some Kudo cards — these are free-to-download cards that you can use for thanking and praising people in your team.

Reflect on how you share praise within your team. How do you pass on positive feedback from patients? How could you improve this?

Reflect on ways to improve communication within your team. You may want to discuss with a colleague or at a team meeting. One technique we have found helpful for these discussions is called TRIZ.

Read about human factors. Communication, teamwork, and resilience are some human factors which can affect safety. The environment in which individuals and teams work, as well as aspects of the task itself, can also have an impact. Human Factors in Healthcare: Common Terms published by the Clinical Human Factors Group is a great introduction to some of the terms used in this field.

Watch The Voice Inside videos and use in conversation with teams — these explore a number of cultural factors affecting maternity safety. The RCOG has also produced a great video on Human Factors and Situational Awareness.

Read the book Black Box Thinking by Matthew Syed.

Read the book How to Have a Good Day by Caroline Webb.

Read Human Factors in Healthcare by Debbie Rosenorn-Lanng — available in two parts (Level 1 and Level 2).

Watch videos on Human Factors produced by the Clinical Human Factors Group

Ask a member of the AHSN team to present our human factors awareness session at a team meeting.

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