HealthLeaders, March 2012
Birthing Centers Blossom
Joe Cantlupe, for HealthLeaders Media
They resemble deluxe hotel rooms, with luxurious décor in soft pastels, inviting paintings, richly upholstered chairs, and don't forget the iPod docking stations, the HDTVs, rollout beds, and room service. Only a blood pressure monitor seems out of place—although that may be hidden in a cabinet.
These are the attractions of birthing centers in hospitals that are seeking to capitalize on the demands of women who want a more personal, natural experience to greet their newborns, instead of the sterile environments that had been the hallmark of hospital deliveries for generations.
While some hospitals aren't interested in either expanding or building birthing centers, others are finding a niche market. Hospitals are not only competing against each other, but also with freestanding facilities. That's because of demographic blips. While birth rates are decreasing generally in the country, in some areas rates are on the rise.
The United States underwent a mini-baby boom for several years, but birth rates began to decline in 2008, and the decrease appears to be linked to the recession, according to a Pew Research Center analysis of state fertility and economic data. In 2010, the preliminary estimate of registered births in the United States was 4 million, some 3% less than in 2009, according to the National Vital Statistics Reports.
By investing in birthing centers, however, hospitals are not only targeting a client base for today or tomorrow, but for years ahead, says Julie Larson, MS, RN, director of nursing at the birthing center at the 425-staffed-bed Regions Hospital in St. Paul, MN.
By enhancing a life-changing experience now for families, hospitals may be able to capture future generations of family and friends. Indeed, expectant mothers are also among the industry's most sought-after patients. Pregnancy and childbirth were the reasons for one in five female hospitalizations in 2009, according to the Agency for Healthcare Research and Quality.
From small to large hospital systems, those that have expanded their programs attribute increases in birth-related admissions to changes in their birth centers. For instance, officials at the 25-staffed-bed Hudson (WI) Hospital&Clinics cited improvements to the birth center for helping to increase its births to 532 in 2010, an increase of 11% over the previous year, and 621 births in 2011, according to Joanne Donhowe, RN, birth center manager at the hospital.
Larson says that hospitals having "hotel-like" birth centers also is a way that they can better compete against freestanding facilities unaffiliated with hospital systems, which are often seen as less expensive and having more of a homey feel than hospitals. That's changing, Larson says. Not only are hospitals delivering the amenities, but they also can offer the comfort and security of knowing that in case of any problems in delivery, the hospital can handle that, too, she says.
Patient comfort is important, but so are clinical improvements to generate ROI for birth centers, says Ann Hendrich, RN, PhD, FAAN, vice president of clinical excellence operations and executive director of the patient safety organization for Ascension Health, based in St. Louis.
Ascension Health, which has nearly 18,000 beds across 70 hospitals in 21 states, is among the hospital systems refining their clinical programs to improve obstetrics patient care through programs aimed at reducing infection rates and medical errors, and thwarting potential malpractice lawsuits.
Ascension Health provides obstetrical services for more than 73,000 deliveries each year. In 2010, the health system reported neonatal mortality rates at 0.83 per 1,000 live births—82% lower than the estimated national rate of 4.5. The corresponding birth trauma rate was 0.7 per 1,000 live births—62% lower than the estimated national rate of 1.84, according to the hospital's reports to AHRQ.
"Our priority is patient safety and patient-centered approaches to foster the added benefits of removing waste and needless additional cost in healthcare. And the better we get, the more we improve care," Hendrich says.
"In a community hospital, one of the ways we survive is bringing a strong foundation for a family and establishing a relationship, and we do that with the birthing center," says Sheri Milone, CEO at the 120-staffed-bed Lovelace Women's Hospital in Albuquerque, NM. Hospitals that don't invest in birthing centers could face the possibility of losing women consumers "at a child bearing age, and many hospitals are struggling to get those consumers back."
Success key No. 1: Beating the competition
Concord, MA–based Emerson Hospital's birthing center was made to ensure a welcoming environment for families and their newest arrival. The 179-bed facility's birthing center includes rooms with Internet access and beds for spouses, who can stay in the hospital and telecommute to work from a comfy, cozy setting.
The hospital's amenities are designed to attract families and friends and represent the patient-centered focus of the birthing center. The result is overwhelming patient satisfaction at more than 95%, says Joyce Welsh, RN, MSM, vice president of patient care and chief nursing officer at the hospital.
There were 2,000 births reported at the hospital's birthing center in 2010 and 2,100 in 2011, a 5% increase, according to Welsh.
The birthing center provides one-on-one nursing care, high-risk pregnancy services, and a special care nursery for babies who need extra medical attention. Among other things, it offers lactation consultants, nursing educators, and a benefit known as boarder status, allowing discharged mothers who have babies in special care to remain in their rooms as long as space allows.
The hospital also has developed an online education program for expectant parents and families, Welsh says.
By having such amenities, "patients have really loved their experience, and we have been able to measure that in terms of very high patient satisfaction," says Jeff Reilly, MD, head of the hospital's pediatric unit. "People are spreading the word."
Hospitals such as Emerson are making the improvements not only for their local demographics and the goal of targeting an increased patient population, but also with an eye on something else: the competition.
Birthing centers are sprouting in cities and suburbs as hospitals seek to attain ROI by outdistancing their healthcare neighbors. It's no easy task.
The Buffalo (MN) Hospital, a 45-staffed-bed facility, has incrementally expanded its birthing center since the 1990s as it kept tabs on its growing population base. After making modest adjustments in the 1990s, it built a new floor devoted to a birthing center, essentially doubling its size and added amenities, such as comforting artwork, music, Internet access, TVs, and 24-hour meal service. The Allina Hospitals and Clinics, Buffalo Hospital's parent company, made it a priority by investing $6.1 million, while the Buffalo Hospital Foundation has raised $850,000 so far toward a total of $7.1 million in improvements.
Not only does Buffalo Hospital want to continue to provide comfort to families, but it also wants to be competitive. Gretchen Frederick, RN, director of patient care at the hospital, counts off the nearby hospital facilities opening birthing centers: one 40 minutes away, another 9 minutes away, and a third 15 miles away.
Several years ago, Buffalo expanded its amenities to respond to patient needs, and surveys indicate high patient satisfaction, she says.
Over the past year, Buffalo had 626 births, which was a record year, and projects at least 700 for 2012. The hospital had projected 1,000 births for 2013, but Frederick believes that goal may not be reached. Still, the hospital is contemplating improvements to the birthing center for increased ROI, as it waits out the "ebb and flow" of population growth, which has slowed in the area, Frederick says.
Buffalo is in the planning stages of adding to its labor-delivery and C-section suites to meet continued demand, she says. An important element is the demographics of the area itself, which could give Buffalo an advantage. Buffalo is located 30 minutes northwest of the Minneapolis-St. Paul metropolitan area and has a population of 15,543. In 2009, the city reported that the population increased more than 42% from 2000.
"We are continuing to look at the business case for improvement," says Frederick. "We're actually the fastest population growth area in [Wright County] for young families. You focus on what your market bears."
Success key No. 2: Better communications
Officials of Regions Hospital, a 425-staffed-bed facility in St. Paul, MN, looked to improve the clinical aspects of their care by establishing standardized protocols to monitor births and improve communication with patients.
In one of the protocols, the hospital established a bundling strategy to properly account for materials used in vaginal deliveries.
The hospital's program has significantly increased compliance with recommended care over time, says Julie Larson, MS, RN, director of nursing at the Regions Hospital birthing center.
A standard process includes guiding clinicians in response to information gathered during fetal heart rate monitoring, ensuring proper notification protocols involving physicians or midwives, and empowering nurses to activate a surgical team when a cesarean might be needed, according to a report Larson wrote for the AHRQ's innovation program.
"We want to focus on the communication strategies," she says. "We can't go on assumptions about what a person is thinking, even though we may be facing that person. We need to be on the same page and need to express our thoughts in those critical moments. We have just minutes to make a critical decision, and in a caesarean birth, that will affect the outcome of the baby in the future."
Larson says that improving communications among staff was needed because they used terms like minimal variability or moderate variability in their conversations, but those terms meant different things to different people. The result: a wide variation in the way clinicians responded to sometimes-critical information.
Larson says a "multipronged strategy" based on guidelines developed by the nonprofit organization Institute for Clinical Systems Improvement has successfully resulted in full compliance with protocols designed to prevent any staffers from unintentionally leaving a foreign object in a patient during a vaginal delivery.
Nurses involved in the procedures complete a checklist to document the use and removal of needles, sponges, or other objects used in the procedures. The hospital accounts for the procedures with a regular audit as well as unannounced audits from a nurse designated by a review staff known as a unit practice council and overseen by nurses. The ongoing audits have shown increased compliance with the protocol, from 95% in 2008 to 100% in 2009 and 2010, according to Larson.
The hospital also established initiatives to improve staff communication with patients, she says. The hospital has a standard procedure in which nurses and doctors acknowledge patients by name, introduce themselves, explain their functions, and provide patients with a card that has a photo of the provider who is in charge of the patient's care. The procedure is based partly on a framework called AIDET, for acknowledge, introduce, duration (letting patients know if there is a delay and how long it will take), explanation, and thank you.
Success key No. 3: Water births
When the Lovelace Women's Hospital opened its natural birthing center in 2010, it sought to provide a place for women who wanted a natural delivery while avoiding medical interventions. It also offered water births, which have become one of the most popular aspects of the center, says Terri Caspary Schmidt, CNM, a nurse midwife with ABQ Health Partners, which is under contract to run the birthing center's water birth program.
While some hospitals are reluctant to embrace the concept, others like Lovelace are diving in. Schmidt says the birthing center has continually increased its patient load, and hospital officials believe that the water birth program is somewhat responsible for that. The hospital noted that the "new service is being provided to meet the growing demand of mothers, families, and providers who seek a more peaceful and natural birth process."
Water birth is a procedure for birthing that involves immersion of the mother in warm water, or using water as part of the labor process.
The Lovelace Women's Hospital includes a 41-bed mother-baby unit, as well as 16 labor and delivery rooms. The birthing center also has four private labor/delivery/recovery and postpartum rooms with water birthing tubs. The 509-bed Lovelace Health System in Albuquerque operates the facility.
Of 350 births at the hospital's birthing center, there were 60 water births in 2011, according to Schmidt.
Proponents believe this method is safe and provides many benefits for both mother and infant, including pain relief for the mother and a less traumatic birth experience for the baby.
"Many mothers find that labor and delivery can be an intense process. Women who choose to labor and deliver in our tubs find that the water's buoyancy relieves pressure and that the constant temperature provides comfort," says Schmidt.
"Additionally, water facilitates a method of pain management, which helps relax the patient and relax the pelvis," she says.
Success key No. 4: Reducing malpractice claims
While the Ascension Health System works to improve outcomes in the birth process, it also is considering something else: efforts to reduce potential malpractice lawsuits.
The hospital system is seeking to improve patient safety at the time of delivery and reduce self-insurance expenses by improving management of adverse events, says Hendrich. The program seeks to reduce the overall expense of malpractice funding for obstetrics.
Ascension is focusing on the perinatal experience for the mother and the child and working with care providers to improve safety and reduce medical claims through a federally funded study, which Ascension created.
To do so, Hendrich says, the hospital system seeks to make improvements in specific protocols at its birth centers.
A major area that the hospital system is focusing on is shoulder dystocia, which occurs when an infant's head passes through the birth canal, but his or her shoulders get caught, either because of the weight of the infant or the small pelvis of the mother. If a doctor attempts to deliver the child without changing the position of the infant's shoulders, it could result in physical impairment. Incidents of shoulder dystocia have been the subject of much litigation, with malpractice attorneys often focusing on whether surgeons or medical staff took proper precautions or preventive measures involving monitoring position of the baby.
The hospital system is working on various protocols "to determine a series of maneuvers that could make a difference" in delivery and lessen the possibility of shoulder dystocia, she says. Those protocols involve physician, nurse, and other staff oversight and response, she adds. "If the infant is not delivered in a timely manner, it can necessitate instant attention," Hendrich says. "We developed standardized education modules in which all physicians and nurses are trained on the same content and tested with the same material in order to act as a collaborative team."
The training not only involves the clinical aspect of care, but also covers the possibility of litigation, with the intent of reducing it, Hendrich says.
If there are problems in delivery, "our physicians and nurse teams are sitting down with the mother and family and fully disclosing what happened," she says. "Medical disclosure, although we like to think it happens the same everywhere—it doesn't. This is a very patient-centered model. When something unexpected happens, a patient deserves to know.
"In an event that is unexpected and discloses harm, we're working on a program to avoid long, protracted medical liability cases. We know that medical liability and serious adverse events can be closely linked," Hendrich says.
"We are collecting data from the mothers' charts and new data for the study in real time," she says. Five hospitals within the health system have begun tracking the "human story" of the changes. "Full disclosure is empowering for the physicians and nurses, and it's the right thing to do for the mother."