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Hospital sees openness with patients key to improvement

As Cleveland Clinic Indian River Hospital’s foundation kicks off a $12.5 million maternity ward renovation campaign, the hospital’s medical leaders are taking a hard look at quality measures in maternal and child health.

That laser focus, as they call it, includes attaching doctors’ names to patient data; previously such tracking was “blinded” – with providers lumped together anonymously in the hospital’s reporting.

Unmasking individual doctor’s performance proved dramatically helpful in lowering the rate of episiotomies, a once-common practice of surgically widening the perineum as the baby first emerges during childbirth.

That procedure, now seen as carrying risks of infection and fecal incontinence, has dropped at the Vero hospital from 18 percent to around 7.8 percent. The national goal, as established by hospital safety and quality organization The Leapfrog Group, is 5 percent.

“Everyone’s competitive, right?” said Megan McFall, director of women’s health at Cleveland Clinic Indian River, talking about unblinding the data. “Let’s just let each other know how we’re doing as practitioners – Dr. X or Dr. Y are providing X number of episiotomies – so you know.”

Along with episiotomies, unblinding the data will apply to c-sections “in the near future,” said Indian River marketing director Angela Dickens.

“If they would do that with cesareans, I would be very happy,” said an enthusiastic Andrea Berry, CEO of Indian River Healthy Start Coalition, which will have offices in the renovated maternity ward.

C-sections are a staggeringly common and increasing problem. Not counting cataract removal, they are the most common surgery American women undergo. They also contribute to higher medical costs, running an estimated $3,000 more than vaginal births.

Considered major surgery, C-sections put a woman at greater risk of delivery complications including site infection and hemorrhage.

“There’s no doubt it contributes to issues like maternal morbidity,” said Berry.

Even when everything goes well, C-sections require a much longer recovery period than vaginal delivery at a time when most women are facing physical and emotional exhaustion.

“If you had different major surgery, you would be kept in the hospital and you would be cared for. But when you’re home with a new baby, you’re expected to snap out of it and take care of the baby, and oh by the way, feed the baby with your body,” said Berry, whose organization sees new mothers in the hospital and continues to counsel them at home.

“It’s a weird thing that we don’t give the reverence to that surgery that we should and give that mother the time it takes to heal.”

Twenty years ago, the overall national C-section rate was 22 percent – and that was considered high. The World Health Organization believes a rate of between 10 percent and 15 percent would be appropriate without compromising maternal or infant health, but the national rate in the U.S. today is 31.9 percent.

In Florida, the rate is even higher, one of the worst in the nation at 36.8 percent. The Indian River County rate is nearly as high at 35.2 percent.

That overall rate includes women, both low and high risk, who were residents of the county, regardless of where they delivered. Of the 1,294 births in the county, 1,064 were at Cleveland Clinic Indian River; 220 women delivered elsewhere.

Healthcare rating organizations and government agencies also track the rate of C-sections among various subsets of patients, including low-risk women.

The low-risk C-section rate, increasingly recognized as a more meaningful statistic than the overall rate, was 25.9 percent nationally and 30.6 percent at Cleveland Clinic Indian River.

The Joint Commission, an independent, nonprofit healthcare watchdog known for its rigorous hospital accreditation process, recently announced it will begin flagging hospitals with a rate higher than 30 percent on its Quality Check website next year.

In addition to her duties at the hospital, McFall, who grew up in Vero, oversees Partners in Women’s Health, an OB-GYN practice funded by the Hospital District and staffed with Cleveland Clinic-employed doctors. Because Partners delivers three-fourths of the babies in the county – there are two private practice physicians as well – the clinic is in a unique position to improve maternal health.

McFall is widely recognized for her efforts at the hospital and with the county’s agencies involved in maternal health; Berry called her a “visionary” whose ability to pick up on trends in maternal and child health makes things “better for every mom.”

Allen Jones, a Hospital District trustee deeply involved in maternal and infant health issues, called McFall “a terrific resource for Partners,” and “an expert in providing and managing care at the hospital.”

There are currently six Partners doctors. With one set to go on maternity leave in February and another working part-time, McFall says the clinic expects to replace those positions with three midwives – a move that could help lower C-section rates at CCIR.

A study published last month analyzing 23,000 deliveries found that mothers using midwives had a 30 percent to 40 percent drop in C-sections, when compared to women who went through labor under an obstetrician. That improvement could be due to the education and psychological support midwives give women as they approach delivery day.

Research has shown mothers aren’t as concerned about C-section rates as public health experts are. Pregnant women tend to choose a doctor first; the hospital is typically default choice – wherever the doctor likes to deliver. In the case of Cleveland Clinic Indian River, it is the only hospital in the county with maternity services.

Despite that relative lack of concern among expectant mothers, hospitals are realizing that paying attention to maternal quality improvement measures can have marketing benefits – it reflects not only openness with patients but the urge to do better.

Berry cited one Florida hospital that is putting name tags on labor and delivery doctors and nurses that say, “Ask me about my C-section rate.”

“When people ask, they flip the tag over, and the rate is printed on the other side.”

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