A critical evaluation of health care reform in maternity services in the Western Cape Province of South Africa, 2007-2012

Gebhardt, Gabriel Stephanus (2016-12)

Thesis (PhD)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: This thesis is a critical evaluation of the impact of service delivery shifts within maternity care on the clinical governance of a well-defined geographical service delivery area (Metro East section of the Cape Town health district) during 2007 to 2012. This period saw the implementation of a comprehensive health plan that envisaged the provision of safe maternity care at a non-specialist hospital within the metropolitan area. The data presented in the first part of the thesis shows that well defined levels of maternity care can provide safe management of pregnancies in a large, well-functioning district hospital. A central event in this time period was the opening of a newly-built district hospital in Khayelitsha and the major change in the drainage boundaries of Tygerberg hospital to include referrals from this new hospital. The thesis presents all the clinical governance aspects that went into the planning and eventual execution of a maternity service and the impact it had on the base hospital. The second part investigates the role of the regional maternity service in Tygerberg hospital as it relates to the clinical governance of the regional and district service in the Metro East sub-district. To this extent a few chapters place quality of care aspects such as structural audits, caesarean section rates, maternal and perinatal mortality data, medico-legal liability, patient and provider satisfaction and protocol compliance within this context. An in-depth root-cause analysis was made of all the obstetrics and gynaecology medico-legal cases within the Western Cape which showed that poor clinical note keeping was a major factor hampering defence of cases. The information obtained from this thesis builds on the Western Cape healthcare plan for 2030 aimed at improving quality of care and wellness with an outcomes-based approach and the prioritisation of evidence-based interventions. It concludes with the description of a maternity dashboard for the Tygerberg labour ward and the Metro East maternity service based on the information obtained from this thesis. The tool can inform the hospital management on progress, successes and challenges within the system on a regular basis.

AFRIKAANSE OPSOMMING: Hierdie tesis is ‘n kritiese evaluasie van die impak van ‘n verandering in die diensleweringsplatform binne die konteks van verloskundige sorg in ‘n goed-omskrewe geografiese gebied (die Metro Oos deel van Kaapstad se gesondheidsdistrik) tussen 2007 en 2012. Tydens hierdie tydperk het die provinsiale gesondheidsdepartement ‘n omvattende gesondheidsplan geïmplementeer. Hierdie plan het voorsiening gemaak vir die lewering van veilige sorg vir swanger vouens in ‘n groot distrikshospitaal binne ‘n stedelike gebied. Die data wat in die eerste deel van die tesis weergegee word bewys dat hierdie sorg veilig kan geskied met die gebruik van goed gedefinieërde vlakke van sorg. ‘n Omvangryke verandering het in dieselfde tyd plaasgevind deurdat ‘n nuwe hopsitaal in Khayelitsha gebou is en die dreinasie grense van Tygerberg hospitaal is verander om hierby aan te pas. Die beplanning rondom kliniese bestuur van hierdie nuwe diens en die impak wat dit op Tygerberg se verloskunde diens gehad het word ook hierin bespreek. Die tweede deel van die werkstuk het die verwantskap tussen die spesialisdiens by Tygerberg hospitaal en die streeks- en distriksdiens in Metro Oos ondersoek. ‘n Paar hoofstukke oor strukturele audits, keisersnitkoerse, moederlike en perinatale mortaliteitsdata, medies-geregtelike risikos, die tevredenheid van pasiënte en gesondheidswerkers asook die nakoming van protokolle bespreek hierdie verwantskap en plaas dit binne die konteks van sorg en kliniese bestuur in Metro Oos. ‘n Omvattende ontleding is ook gedoen van al die medies-geregtelike gevalle wat deur die provinsiale gesondheisdepartment hanteer is. Dit het onder andere gewys dat kliniese notas in baie gevalle benede standaard was. Die tesis eindig deur voort te bou op die Wes Kaap regering se 2030 gesondheisplan wat die kwaliteit van pasiëntsorg hoog op die hart dra. Dit beskryf die ontwikkeling van ‘n meetinstrument spesifiek vir die Tygerberg kraamsaal wat op ‘n gereelde basis inligting rondom pasiëntsorg weergee. Dis veral belangrik vir die bestuurders in die diens en die suksesse en uitdagings binne die diens kan hiermee aangespreek word.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/100351
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