The Current Climate and Your Clinical Microsystem

Most of us know

  • All the incentive levers are not pushing in the same direction.
  • Errors evolve from chaotic work environment, fatigue, and systems failures, leading to waning vigilance, inattention, and haste.
  • Previously successful business and practice models are no longer working, as reimbursements and revenues for highly technical and specialized services have significantly outpaced those for routine obstetrical care, which we know is necessary care from a public health perspective.
  • Chronic and acute crises in the professional liability arena have become a way of life for most of us and our colleagues.
  • There is a declining and changing workforce in obstetrics. This will impact rural areas first, but eventually will touch most of us and our families. Fewer people are entering obstetrics and many are leaving.
    • OB/GYN has been among the last choices for graduating medical students in recent years. Of those medical students who do complete OB/GYN residencies, many will follow career paths that do not include delivering babies.
    • Midwifery graduate programs in universities are closing due to a decreased pool of applicants (e.g., BU's CNM/MPH program closed Spring 2006).
    • Midwives, obstetricians and nurses change their work patterns as they age. They do less, not more, obstetrics.
    • Nurses have many opportunities that do not have the demands and stressors of staffing an obstetrical unit.
    • Fewer family physicians provide obstetric services.
  • Litigation and professional liability insurance are the top issues for ACNM and ACOG. Resources that are being used to address these issues are being diverted from worthy clinical, educational, and service projects. Neither organization can point to significant successes in the regulatory or legislative arenas despite investment of time and resources.
  • Simply following national guidelines is not always the answer:
    • They are not always clear and definitive, such as "immediately available" per ACOG regarding VBAC, 2004.
    • They are not always adopted and implemented locally, even when there is consensus and they are in the best interest of patients and providers. Examples include NICHD nomenclature; Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia per ACOG, 2004.

Some may not know

  • There is unprecedented attention to patient safety and quality measures that will be accompanied by rigorous scrutiny of our clinical competence. This demands that we acquire new knowledge, attitudes, and expertise to participate. It is predicted that these efforts will continue to gain momentum and will be a predominant theme in the nation's health care over the next decade.
  • When confronted with similar workforce and professional liability challenges in the 1990s, anesthesia redirected resources and became clinical leaders in the patient safety movement, with good results for patients and for their profession.
  • Performance Based Payment (PBP) or Pay-for-Performance I (P4P) is on the horizon. The good news is that we have time to put strategies and data collection tools in place before payment structures and performance measures are linked.

These issues cannot be separated on a day-to-day basis and must be worked on in an integrated fashion, with cohesive solutions identified system-wide and region-wide.

For more information about the Obstetric Safety Initiative, or to offer suggestions or additions to this site, contact us.