BIRTHING FACILITIES CONSULTING

As hospitals are held increasingly accountable for health outcomes and satisfaction of childbearing families and the maternity care workforce shortage grows each year, it has never been more critical to reconfigure hospital staffing models. Of key importance is to understand and successfully integrate all available roles and providers into birthing facilities with them practicing to the full scope of their education, certification and licensure.

Decades of research and data from countries that spend far less on maternity care with better outcomes, demonstrate successful integration of Midwives. ACOG continues to endorse advancing Midwives in team-based models of care by providing the right provider, for the right patient at the right time.

Grow Midwives brings over 70 years of combined experience integrating midwifery-led models as Chief Midwives and Service Directors in community-based and academic teaching centers. Our goal is to facilitate the role of Midwives in hospital settings whose mission is to provide quality care that improves the health and well-being of childbearing families.

HOW CAN WE CREATE A MIDWIFERY LED OR ALONGSIDE BIRTH FACILITY FOR LOW RISK PATIENTS

One of the challenging questions that the midwifery profession is still trying to figure out is, “How do we look attractive in a collaborative relationship? Perhaps it is with a privately owned obstetric group. Maybe it’s 5 obstetricians and 4 midwives. Maybe it’s a hospital based service where physicians are collaborating through mutual employment models. There are many possibilities to fit a variety of situations for different birthing facilities.

How do you figure out your income and expenses in a collaboration? How do you ensure that all parties make some profit margin that’s respective to the body of work that each has done and to their degree of training? How do you measure the level of acuity of services each provides?

Midwives aren’t surgeons. Midwives primary scope of care is in working with normal, healthy people. One of the important things few midwives have thought about, or accounted for in any kind of data collection, is “How much money are they generating based on the services they provide in a given period of time?” Creating this kind of pro forma is incredibly important for Midwives, yet almost never happens today.

HOW DO WE OPEN AN ACCREDITED BIRTHING FACILITY

Opening an accredited birth center would start with understanding what the American Association of Birth Centers (AABC) promotes as exemplary models of free-standing birth centers. Creating environments that emphasize family centered care for low risk maternity patients in an out-of-hospital birthing facility.

Alongside the AABC, is an accrediting body that is not affiliated with, but works in tandem to promote accreditation of freestanding birth centers, the Commission for Accreditation of Birth Centers (CABC).

Birth Centers can be owned and operated by midwives or physicians or hospitals. When you think about accrediting a birth center, again you need to go back to state regulations. About half the states in our country have state licensure regulations that are additional to an accreditation process. Some insurance companies are likely to mandate both state licensure and accreditation before reimbursing for a facility fee. Additionally, some states do not require accreditation of your birth center or have regulatory requirements.

Optimal safe practice is best provided by meeting minimum requirements of CABC accreditation. There is a cost associated with accreditation as with any oversight organization that provides recommendation of quality review. However, Grow Midwives believes this is the most rigorous process demonstrating public safety and accountability. We believe this is a requirement for safe care in all birthing facilities.

PRACTICE DEVELOPMENT

Integrating Midwives in to Team-Based care has been widely endorsed and encouraged by ACOG through association documents, eg. Collaboration in Practice: Implementing Team-Based Care, and journal publications. Quality, efficiency, and value are necessary characteristics of our evolving health care system.
Practice Development through the integration of team-based care models address the Triple Aim of

1) improving the experience of care of individuals and families;
2) improving the health of populations; and
3) lowering per capita costs.

It also should respond to emerging demands and reduce undue burdens on health care providers. Team-based care requires both Physicians and Midwives establish models that are seamless, built on trust, and provide sound principles of practice.

Grow Midwives have over 50 years of combined experience in working with private physician models as well as collaborative models with private OB groups. We can provide proforma data related to cost of scaling up with midwives, as well as target/market employment arrangements and work schedules. Some Physicians are interested in owning their own birth center, led and staffed by Midwives. Our services include expert guidance on how to take concept to reality. Develop your practice from the ground up instead of struggling with every issue as it arises.

HOW CAN MIDWIVES DESIGN A SUCCESSFUL PHYSICIAN/MIDWIFE PRACTICE

One of the challenging questions that the midwifery profession is still trying to figure out is, “How do we look attractive in a collaborative relationship?” Perhaps it is with a privately owned obstetric group. Maybe it’s 5 obstetricians and 4 midwives. Maybe it’s a hospital based service where physicians are collaborating through mutual employment models. There are many possibilities to fit a variety of situations.

How do you figure out your income and expenses in a collaboration? How do you ensure that all parties make some profit margin that’s respective to the body of work that each has done and to their degree of training? How do you measure the level of acuity of services each provides?

Midwives aren’t surgeons. Midwives primary scope of care is in working with normal, healthy people. One of the important things few midwives have thought about, or accounted for in any kind of data collection, is “How much money are they generating based on the services they provide in a given period of time?” Creating this kind of pro forma is incredibly important for Midwives, yet almost never happens today.

HOW TO START A HOSPITAL-OWNED MIDWIFERY SERVICE

When starting a hospital-based midwifery service, the assumption is that you will be an employee of the hospital. Has the hospital ever employed midwives before? A hospital may be starting a service for the first time, having never employed midwives on their staff before, which, again, means looking at hospital bylaws and assisting in designing the credentialing process.

What kind of privileges can you ask for to render care in that hospital environment? Such as, can you admit and discharge in your own name? Or do you have to admit and discharge under a physician’s name? Again, staffing questions need to be answered. Is it just a maternity care service or is it full scope? Are you providing care through the lifespan from young girls through aging women?

Who are the collaborating physicians going to be? It’s unlikely that collaborating physician is going to be a family care doctor, because what if the patient needs a cesarean section and they don’t have privileges to do surgery. However, some family physicians have additional training and perform c-sections. If midwives are working in rural health in a hospital team that is primarily family physicians, internists and surgeons’ how can a midwife bring additional assistance to this team?

You need to think about where the hospital is located in terms of resources they have and levels of care that they provide. What does the target market population look like? What is the case mix of the potential caseload? What will insurers cover as a licensed provider?

HOW TO INTRODUCE EBP IN MATERNITY CARE PRODUCT LINE

There are many Evidence Based Practice (EBP) clinical options that deserve more attention by the healthcare community.

Take Nitrous Oxide, it’s slowly emerging across the country as a pain management tool in labor. It is widely used in Europe and contributes to positive outcomes while providing safe care for mothers without risk to the baby.

There are also a number of practices that are non-pharmacologic that hospitals may just not know how to effectively implement, train, orient or evaluate yet. Some of these may be best practices that lead to reducing the number of cesarean sections in a hospital, incorporating doulas into a hospital, providing the option of water in labor in birth, and a variety of other practices that are evidence based.

HOW DO WE ADDRESS BURNOUT AND ATTRITION IN THE WORKPLACE

Burnout and attrition are significant issues for all health professionals, especially for people whose careers require call time. Physicians and Midwives face this challenge of having to cover 24/7 every day. In addition to a shortage of providers caring for women’s health, there is an overabundance of patients.

Grow Midwives has learned over the last few years that there is an exhaustion factor that comes with working really long shifts. Sometimes for 24, 48 or even 72 hour shifts Midwives are literally on the entire time.

They may have short, little breaks that are built in, but early in 2017 ACNM released a Position Statement suggesting Midwives should not work longer than 16 continuous hours without 4-hours of uninterrupted rest, as well as additional recommendations.

The question then becomes, “Are we not staffing the units properly?” Are we so committed to continuity of care that we don’t realize that a specific Midwife doesn’t have to be the one attending the birth. It could just as easily be one of the other partners. It could be another person in the hospital who doesn’t know the patient at all. What is an appropriate level of personal sacrifice and safety in care delivery versus patient expectation?

Hiring raises its own needs and questions. Are you hiring people with similar philosophies? In that case, does it really matter which of us is there if we are all going to provide the same style and quality of care?

Burnout and attrition in midwifery is high. People are leaving the profession every year or considering leaving. Some feel that they aren’t being paid enough, some don’t feel like they are being acknowledged for the importance of the job they do, some can not take earned vacation time, so simply are exhausted from poor staffing.

Taking care to structure a balanced and supportive collaborative practice will keep both Midwives and Physicians from feeling overworked, underpaid and under-appreciated.

HOW TO MAXIMIZE REIMBURSEMENT FOR SERVICES

When negotiating reimbursement, you first have to be credentialed by both commercial and public payers. If you are not able to be credentialed on a payer panel as an independent provider, you will not be visible to patients and you will not be able to negotiate what your reimbursement rates are.

Medicaid negotiates reimbursement rates on a state by state basis. Midwives often have to partner with physicians who speak on their behalf to payer panels trying to convince them that Midwives deserve the same reimbursement as Physicians for a normal, healthy birth.

Common questions to answer in a hospital setting include: Is a midwife going to bill under their name or under a physician’s name? Who is going to be reimbursed and how much? Whose name is on the birth certificate? There are many strategies that can be employed to navigate all of these questions and more.

MIDWIFE CAREER SERVICES

Midwives are often busy, too busy to think about or spend time on health, wellness and equitable salary, let alone value one brings to employment settings. Grow Midwives offers unique midwife career services that span legal consultation on employment contract agreements, renegotiating one’s salary, resolving conflict with peers in practice, improved marketing, and how to start a private practice or birth center, from concept to reality.

Our aim is to facilitate ready and capable midwives in to happy, stable practice relationships that foster high quality care and options for childbearing families and women thru the lifespan. Consultations can be as short as one hour video calls to multiple-day packaged services such as retreat facilitation, coaching on interviewing techniques, and facilitating conflict resolution.

HOW DO I START A MIDWIFERY PRACTICE

The first thing you need to do when starting a Midwifery practice or service is investigate the licensure and regulations process in the state where you want to practice. If you are planning to practice on a state line or in more than one state, you will need to look into each state’s regulatory requirements.

You need to understand how the design of a practice is legally regulated. What are your states regulation requirements for consultation, collaboration, and referral to a higher level of care for clients who need care outside the Midwife scope of practice? Do you license yourself with the State Board of Nursing? The Board of Healing Arts? The Health Department or Public Health Board?

If you’re operating a midwife-owned practice, other essential elements include finding a location. It’s probably going to be based on insurers who are going to reimburse you and assurance you can be credentialed from the hospital at which you want to attend births.

What’s your staffing model going to look like? Solo or with a couple partners? How are you going to run the office and non-medical side of the practice? There are a variety of things to consider just in terms of legal and financial questions.

If you are attending women in a hospital, does that hospital have bylaws that allow non-physician providers to maximize hospital privileges. If they do, what do those bylaws indicate in terms of scope of practice, admission, and discharge: things that are elemental to hospital providers, and delineated in bylaws of that hospital.

Then, is there an understanding of how to create a list of privileges that allows the Midwife to practice the scope that they are trained to do and beyond. Can they first assist? Can they repair a third or fourth degree? Can they use a vacuum extractor? I’ve mentioned things that are all not taught in Midwifery education, but are skills Midwives do beyond their educational training through additional certification programs. How do you credential somebody who wants to first assist in surgery with your patient needing a c-section? How do you know they have the necessary skills and training? There are mechanisms that can be put in place to assure competency.

HOW TO FACILITATE DIFFICULT CONVERSATIONS IN THE WORKPLACE

The idea is how to approach the problem with some preparation to dispel what you would call “intention invention” or projecting what the other person is doing and why they are doing it.

Try to come up with some ideas, so that you have some kind of empathy. Try to start a dialogue in an open question environment. You will then begin to discover things you might not have found if you stayed mired in the original position.

Facilitating difficult conversations requires the ability to look at things with an empathy to the other side, with some preparation in regards to what you really want, how you want it, and alternatives to how you want to get there.

Good negotiators are civil, well informed, will challenge trespasses, but be quick to forgive those trespasses. To train people to deal with difficult conversations is a matter of both an empathetic review of how to deal with conflict, but also raising the bar on what truly is difficult.

In many environments, when you are dealing with one that is in collapse, every issue is so impacted and so layered with “this is what it really means” kind of statements, that almost anything from the whether the birthday cake for the last employee birthday was vanilla or chocolate becomes an issue. If you can figure out how to raise that bar back up, past an adult level and into a professional level of what an insult really is, you can then have conversations that ease those tensions and open up dialogue.

A difficult conversation tries to drill down to a more granular level on both sides of what really are the needs, concerns and points on both sides.

HOW TO NEGOTIATE MUTUALLY BENEFICIAL EMPLOYMENT AGREEMENTS

For the most part, a normal employment agreement for a Midwife deals with salary versus how many hours they work on call and in the office, as well as other perks. The way a compensation package is structured in terms of rate and style can help alleviate overwork, feelings of under-appreciation, and burnout.

The most common issue that normally happens is that after an employment agreement is entered into, the number of working hours increases substantially. There are also questions related to the realities regarding malpractice coverage, non-compete agreements, and a host of other legalities.

ADVOCACY

Overall, women in America think the quality of maternity care is good. (According to Listening to Mothers III Key Findings) However, mothers are increasingly aware of media attention over the last twelve months highlighting the high rate of maternal death in the US. A rate higher than any other high-income country in the world, yet the US spends more money on maternity care than any other country and experiences worse outcomes. It is estimated 700 women die each year from childbirth-related events, and over 50,000 women per year experience a near miss event. Consumer awareness about this growing crisis should not scare women and families but activate those considering growing their family to learn about many issues that contribute to poor outcomes.

Grow Midwives is committed to educating consumers to engage in their care, and make the best choices for their provider, place of birth, and engagement before, during and after childbirth. We are committed to education through free distribution of infographics and resources to guide learning. We are also nationally renowned speakers, willing to speak at venues that you believe could advance the role of safety, quality and improved outcomes in maternity care, particularly by scaling up midwifery.