It’s no surprise that the alarming maternal morbidity rate in the US has created a major drive to improve the safety and quality of maternal patient care. Hospitals should expect to see greater emphasis on labor and delivery performance and outcomes as the nation works to make the US a safer place to give birth. A quickly growing model which helps to address these challenges is the OBGYN hospitalist program.
The OBGYN hospitalist concept is a fairly new speciality which is working on standardizing its competency guidelines and metrics. From the program design to the definition and responsibility of the role, there is a considerable variety. Simply having an OBGYN in the hospital is not the same as having a hospitalist program and even an established program may be dysfunctional. A successful hospitalist program will see a better return on investment for the services provided including leadership, billable encounters, reduced malpractice costs and an overall improvement in safety and quality of care. Although this is a new concept, healthcare systems can draw upon the knowledge of industry leading experts with sound processes. Evaluation of a labor and delivery unit or existing hospitalist program is an important step towards an improved and successfully running program.
Currently there is no formalized system to rate hospitals and obstetric departments. The Society for Maternal Fetal Medicine (SMFM) and the American College of Obstetricians and Gynecologists (ACOG) recommend a classification system for levels of maternal care. This pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for high risk pregnant women to receive care in facilities that are capable of providing the required level of specialized care. This system should reduce maternal morbidity and mortality.
Hospitals report c-section rates to the Joint Commission*, but these statistics are not easily accessible to the public since hospitals are not required to publicly report this information.
Looking at both qualitative and quantitative data can offer a complete picture when evaluating an obstetric department or an existing OBGYN hospitalist model. Monthly tracking and quarterly and annual review of data allows teams to make changes before a problem grows, and if needed, advisable next steps and solutions are made to support and address challenges. By combing through the details, evaluating data can help pinpoint areas of program stress.
Concrete numbers help decipher trends. Important quantitative data to track and review are:
- Critical incidents and adverse obstetric outcomes (such as postpartum hemorrhage, blood transfusion, maternal ICU admission, maternal death, return to the operating room, 3rd and 4th degree lacerations, uterine rupture, 5 minute APGAR score <7 at 5, fetal traumatic birth injury, intrapartum or neonatal death and unexected NICU admission)
- Nulliparous, Term, Singleton, Vertex Cesarean birth (NTSV) rate
- Vaginal birth after C-section (VBAC) rates
- Unattended birth rates (when a doctor or midwife is not present for the delivery)
- 24/7 OB/GYN coverage
- Billable and non-billable events (how often is the hospitalist called to stand by)
Qualitative data is equally valuable, and can show critical signs of program flaws that numbers miss. These are key areas to observe:
- Team culture and dynamic
- Guidelines and protocols designed to improve quality care
- Team satisfaction
- Critical and life-saving stories plus “near-misses”
I’ve worked with established hospitalist programs that needed evaluation for various reasons. Some weren’t sure if they were implementing a hospitalist program correctly, while others wanted to further improve what they had already started. There are also hospitalist programs that were just not working the way they were designed. Fortunately, the hospitalist programs I’ve been involved with are running smoothly, but in my experience when a pre-established hospitalist program is not working it’s due to these four areas:
A hospitalist is there to support the entire team. Open communication encourages anyone to speak up when there is a concern. Briefing and debriefing cases provides a forum for team interaction. This culture of reliable communication makes a more competent and reliable team. Today when resources are stretched and outcomes are closely tracked, teams must be collaborative to create a unified shared labor and delivery unit. A hospitalist may work with perinatologists, midwives, maternal-fetal medicine specialists, the emergency department, family physicians, OBGYN colleagues, and an OBGYN or Family Medicine residency program. Effective communication and a collaborative mindset is a must.
Lack of standards and protocols
A hospitalist program is a cross-functional system involving many people. Variation in processes can create inefficiencies, confusion and medical errors. It’s important that everyone knows their role and what to do, not only with emergencies, but with day to day care.
A great OB/GYN isn’t necessarily a great hospitalist
Hospitalists that transition from their own practice may find the work environment quite different from what they’re used to. Hospitalists that are collaborative, flexible, team players, and have an attitude of service thrive in their role. If they are not accessible, proactive, and asking their team “how can I help you”, the program will not function at its optimum.
A key benefit of a hospitalist is the support provided when emergencies strike. Often faced with high-risk events, a hospitalist should be experienced to handle these cases. Since the OBGYN hospitalist is a new specialty, skills vary. The Society of OBGYN Hospitalists is working to define OBGYN hospitalist competencies to standardize a level of expectation and performance. SOGH has asked Dr. Olson and Dr. Carroll to write the OB ED core competence portion of that publication
It’s exciting to see hospitals seeking to improve the quality and safety of maternal patient care, and choosing the OB/GYN hospitalist model as part of the solution. Every healthcare system is different; therefore careful planning and understanding with a customized approach is essential. A hospitalist model interacts with multiple departments. When integrated properly with effective evaluation, this new specialty will improve patient satisfaction and safety as well as satisfaction for the team and providers.
The National OBGYN Hospitalist Consulting Group has a combined hospitalist experience of 60+ years and are leaders in the industry, actively contributing to improvements and establishing standards towards the OBGYN hospitalist concept and the hospitalist role. If you are considering developing a new OBGYN hospitalist program, improving an existing one, or seeking third party evaluation please contact us.
*The Joint Commission is a United States-based nonprofit tax-exempt 501 organization that accredits more than 21,000 US health care organizations and programs.