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Delivering Safety Over Convenience

Cheryl Clark, for HealthLeaders Media, September 25, 2013

So twice a year, the hospital provided each physician with his or her own data. "How many women they were delivering prior to 39 completed weeks without medical justification. It was eye-opening for them."

"We had a significant number [of doctors] who complied only when we supplied their personal data. They could see what everyone else was doing, and that others were doing it better. They fixed it on their own," Homan says.

Rush-Copley "changed its entire system" to include a hard-stop policy requiring any physician scheduling a C-section or an induction of labor to complete a form listing any medical justification, and required that the maternal fetal medicine specialist sign off on it. That allayed a concern among nursing staff, who didn't want to be put in the position of being a gatekeeper telling doctors they couldn't do what they wanted.

Sometimes there can be questions about the gestational age of the fetus, and in those cases the specialist or department chair may look at the woman's ultrasound, which is considered extremely accurate if it's done in the first trimester, Homan explains.

It's been a "changing culture," Homan acknowledges. "Women had kept pushing their deliveries sooner and sooner, because they're uncomfortable or because their husband was going back to Iraq; they had all kinds of excuses. But these are not medical justifications."

Rush-Copley steers away from fear tactics about early delivery complications that other hospitals may be using. "You can't scare women too much," Homan says, "because what about the poor woman who goes into spontaneous labor at 37 weeks. If we make a big deal about brain development, they'll flip out."

Instead, Homan says, education for the patient should begin even before the woman conceives, teaching "that a normal pregnancy takes 40 weeks. And if you're not willing to allow that normal process, you should think whether you want to conceive."

One poster child for zero unnecessary elective births before 39 weeks is Geisinger Health System, which serves a 31-county region in northeastern Pennsylvania.

John Bulger, DO, MBA, Geisinger's chief quality officer, says the quality gains from having fewer complications and fewer patients in the NICU "far outweigh any of the costs we put into the program." He adds that because Geisinger is a physician-led system, it's the physicians who have made the cultural change, not top down, "but bottom up."

William M. Gilbert, MD, medical director for women's services for Sutter Health's Sacramento Sierra Region's five-hospital 846-bed system in California, said that back in 2010, with the move to measure healthcare quality in many specialties, his system began examining obstetrics.

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