Read standard 3: Leadership and culture

Maternity standards
Healthcare Improvement Scotland

Standard statement

Maternity services have effective leadership, robust clinical governance and a culture of openness and learning.

Rationale

Clinical and staff governance is an integral and essential part of the delivery of high-quality, safe and effective clinical services. NHS boards requirements are provided in the Blueprint for Good Governance and supported by Healthcare Improvement Scotland’s clinical governance standards. NHS boards should ensure that maternity services are underpinned by reliable and effective organisational governance and leadership, including quality and clinical risk management processes.

Reports and inquiries into maternity care have emphasised the importance of robust clinical governance, effective leadership and an open and learning culture.1, 3, 4 NHS boards should ensure a clear line of sight between staff and leaders, including senior managers.3 Maternity services benefit from a triumvirate leadership structure that brings together medical and midwifery expertise, professional insights and managerial and/or operational skills. A nominated Board-level maternity services lead, such as a non-executive director, should provide essential leadership, oversight and assurance. Multidisciplinary teams should be supported by visible, accountable leaders who demonstrate openness, candour, good communication and accountability.

NHS boards should develop a culture of trust in maternity care by fostering compassionate, visible and inclusive leadership and ensuring robust systems for safety, continuous learning and effective communication.16,17 This involves supporting staff and genuinely listening to women and their families.3,18 When a women’s experience is unexpected or results in unwanted outcomes, involving them in reviews and investigations helps ensure their voices are heard and leads to a better understanding of what happened. Clear, respectful communication, support to ask questions and opportunities to discuss care promote transparency, strengthen trust and contribute to continuous improvement in maternity services.

A whole-systems approach to quality and safety is required for maternity care services.16 A structured risk management approach using national guidance will ensure that issues, adverse events or near misses are identified, assessed, managed and escalated appropriately.19 Staff should be supported to be able to raise concerns in a confidential and psychologically safe way.3 NHS boards should also ensure staff are aware of national whistleblowing processes and their organisational and professional Duty of Candour responsibilities.

An effective quality management infrastructure is essential for the delivery of high-quality care. It enables NHS boards to respond to changing healthcare needs through continual monitoring, planning, improvement and assurance. NHS boards benefit from sharing data, identifying ‘bright spots’ and planned improvement.20 A learning system that brings together data and intelligence from different sources supports services and systems to understand performance, plan more effectively and share good practice.

Criteria

3.1

NHS boards enable a positive and open workplace culture by:

  • creating conditions that empower staff to safely share their experiences and escalate concerns, including those relating to leadership and culture
  • supporting effective teamwork
  • tackling discrimination and prejudice and promoting an inclusive and respectful working environment
  • acting promptly and effectively to identify and mitigate clinical and organisational risks and staffing concerns
  • having visible and supportive leadership
  • supporting staff to be role models for effective and compassionate leadership at all levels of their practice.
3.2

NHS boards ensure governance and oversight of maternity services, in line with national policy, guidance and standards, including Healthcare Improvement Scotland’s clinical governance standards.

3.3

NHS boards have effective leadership and staffing governance arrangements for all maternity services that:

  • include a clearly defined and accessible triumvirate leadership structure with designated relevant professional and managerial leads
  • set out clear roles and responsibilities for the escalation and management of clinical risk
  • enable line of sight from ‘floor to board’
  • support direct reporting to the multidisciplinary maternity leadership team and the Executive Board
  • establish regular reporting and review cycles.
3.4

NHS boards have effective governance of:

  • clinical safety and risk management
  • quality management and continuous improvement
  • clinical effectiveness
  • engaging, listening and responding to feedback from women, care partners and staff.
3.5

NHS boards ensure staff have capacity to participate in, and contribute to:

  • inquiries and reviews, including but not limited to adverse event reviews and maternal and infant death reviews
  • internal and external quality assurance activities
  • the implementation of national standards, pathways and clinical guidance
  • benchmarking and reporting, for example key performance indicator data
  • research and evaluation
  • learning and improvement work.
3.6

NHS boards have processes for the management of adverse events, near misses, and complaints, which are aligned with local and national guidance and include:

  • a standard and consistent approach to reporting
  • clear accountability and responsibility for local response, investigation and review
  • detailed actions and learning to reduce likelihood or impact of recurrence
  • mechanisms to report progress against actions and improvement plans
  • processes for sharing anonymised, thematic learning with multidisciplinary teams, governance structures and national learning processes, as appropriate
  • mechanisms to provide timely supportive, constructive and blame-free feedback on the outcomes of reviews to the staff involved.
3.7

NHS boards ensure maternity services have processes in place to support staff to:

  • celebrate success and share good practice
  • talk openly about errors and raise concerns safely
  • act in accordance with national whistleblowing and Duty of Candour requirements
  • respond promptly and in line with professional guidance and national policy if they think patient safety is, or may be, seriously compromised.
3.8

NHS boards provide women (and, where appropriate, their care partners) with clear information on how to raise concerns relating to their care, including the complaints process. This information:

  • is easy to access, understand and complete
  • is accessible in a range of formats and languages
  • includes signposting for further support, information and advocacy
  • includes timelines and process for response and, where appropriate, action.
3.9

When a women’s experience is unexpected or results in unwanted outcomes, women are:

  • supported to understand clinical or technical information with explanations provided in plain, accessible and jargon-free language
  • supported to ask questions, share their experiences and raise any concerns, with clear, compassionate communication and access to appropriate staff for support
  • offered a meeting with relevant staff to discuss their experience, which may include review or investigation findings and any reports produced.
3.10

NHS boards implement an evidence-based whole-systems quality management approach for maternity services, which includes:

  • identification of potential emerging safety issues that require urgent attention and action
  • identification of priorities for improvement, learning and good practice
  • collection and monitoring of feedback and data to inform planning and improvement
  • participation in local and national improvement work, datasets, evaluation and research.
3.11

Maternity services use local and national data and intelligence, including staff and women’s experiences of services, to:

  • identify and learn from positive outcomes and ‘bright spots’
  • identify issues with quality and safety
  • address gaps or inconsistencies in data collection
  • develop intelligence-led improvement plans
  • monitor the impact of improvement plans on quality or safety.

NHS boards have processes to demonstrate how they use this information to improve care.

3.12

NHS boards have systems and processes to ensure maternity services align with all relevant national standards, pathways and clinical guidance. This includes mechanisms for benchmarking and monitoring progress towards full implementation.

3.13

NHS boards ensure local care and referral pathways:

  • clearly set out staff roles and responsibilities for each element of maternity care
  • specify the standard documentation and communication required
  • identify processes for the management, escalation and communication of risks and issues, where appropriate
  • are regularly reviewed and approved through relevant local governance committees.
3.14

Where there is a post-mortem examination following a maternal or neonatal death, NHS boards provide oversight and assurance of:

  • timelines, including actions to minimise delays
  • feedback to staff and families.
3.15

NHS boards have a culture of openness and transparency and publish reports on data and intelligence from feedback, reviews, quality assurance activities, adverse events and complaints that:

  • are easily accessible to women, staff and the public
  • include improvement action plans
  • demonstrate where learning has led to improvements in maternity care and services.

What does this standard mean for...

What does the standard mean for women and their babies?

  • You will have high-quality maternity care and support.
  • Your care and support will be based on current evidence and best practice.
  • You can be confident that maternity services are safe, well organised, monitored and regularly reviewed to make sure they keep improving.
  • You will be able to share your experiences, give positive feedback, raise concerns or make complaints, and these will be addressed in a timely and fair manner.
  • If something in your care does not go as you had planned, or if you have an unwanted outcome, you will be supported to discuss this with staff and be involved according to your wishes.
  • You will be supported to understand clinical or technical information with explanations provided in plain, accessible and jargon-free language.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting, are enabled to:

  • experience effective and compassionate leadership and be recognised and supported as an individual
  • be role models for effective and compassionate leadership at all levels of their practice
  • deliver care in line with national, regional and local pathways, standards, protocols and guidance
  • share what works well and be actively and meaningfully empowered to improve maternity care
  • feel psychologically safe and empowered to share and escalate their concerns, including those relating to leadership and culture
  • report and escalate concerns, feedback, complaints, adverse events to managers, leaders and the Board
  • understand their role in improving quality across the whole system
  • undertake and participate in internal and external quality assurance.

What does the standard mean for the NHS board?

NHS boards:

  • promote a culture of openness, accountability and transparency
  • have oversight and assurance of clinical, care and staff governance across maternity services have a clearly defined and accessible triumvirate leadership structure for maternity services with direct line of sight from floor to board
  • have governance arrangements in place outlining roles, responsibilities and lines of accountability, including for the management of and timely response to adverse events, feedback and complaints
  • ensure quality assurance and ongoing service improvement through routine collection, analysis and review of outcomes and other quality data
  • ensure staff have capacity to undertake governance activities and take part in related activities, including adverse event reviews
  • create and sustain a positive culture where all staff feel empowered and enabled to raise concerns safely
  • enable staff to identify, share and celebrate what works well
  • enable staff to deliver evidence-based care and support
  • ensure staff who participate in reviews are appropriately supported and receive feedback and can access reports and action plans.

Benchmarking and measuring performance

 

Criteria

Examples of what meeting this standard might look like

Please note this list is not exhaustive and examples may vary according to the size and scale of the service or NHS board or delivery model

3.1

iMatter results and action plans.

3.2

Action plans demonstrating implementation of national guidance and standards.

3.3

Triumvirate structure with designated midwifery and medical professional leads.

3.4
3.5

Evidence of staff participation in inquiries and reviews.

3.6

Review of data from perinatal mortality review tools and local significant adverse event review platforms.

3.7

Regular multidisciplinary huddles to review local data and prioritise improvement actions.

3.8

Complaints information provided in alternative formats and languages.

3.9

Evidence of women being supported to ask questions and raise concerns.

3.10

Evidence of participating in national Scottish Perinatal Network, Scottish Patient Safety Programme (SPSP), Essentials of Safe Care and other improvement forums.

3.11

Evidence of use of data dashboards, including progress against key indicators for quality reporting at board level.

3.12

Minutes from relevant governance meetings.

3.13

Local referral pathways with review and approval mechanisms.

3.14

Data on the timeliness of post-mortem examinations with action plans that outline improvement work.

3.15

Published reports on reviews and quality assurance activities.

 

Editorial Information

Last reviewed: 23/03/2026

Next review date: 23/03/2031

Author(s): Maternity standards development group.

Author email(s): his.standardsandindicators@nhs.scot.

Approved By: Maternity standards development group

Reviewer name(s): Maternity standards project team.