Nurses Champion New Patient-Centric Model of Labor and Delivery Care

Cleveland Clinic Akron General began piloting a new model of care in October 2022 on its labor and delivery unit. TeamBirth, a key component of the broader Maternal HealthCARE initiative sponsored by the March of Dimes and the U.S. Department of Health and Human Services, places patients giving birth at the center of shared communication and decision-making with their caregivers.

“Labor is such an intimate, vulnerable time in which patients can sense a loss of control,” says Loretta Creager, DNP, RN, Nurse Manager of labor and delivery, perinatal care, and the obstetrical emergency department at Akron General. “The TeamBirth model gives control back to the mom and ensures that the patient’s voice is heard.”

The labor and delivery unit’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores for nurse communication point to the model’s effectiveness: The score for “nurses listen carefully to you” rose 10.56% in the first quarter of 2023 to 90.48%.

Plan-of-care huddles

Akron General is one of four hospitals in the United States participating in the initial pilot of the TeamBirth model. A group of caregivers attended a one-day training session last fall led by the March of Dimes and Ariadne Labs, which codeveloped the evidence-based approach. The team included a nurse educator, nurse managers, assistant nurse managers and clinical nurses (who serve as TeamBirth champions) from the hospital’s New Life Center, as well as Jennifer Savitski, MD, Chair of Obstetrics and Gynecology, and obstetrician Natalie Bowersox, MD.

Plan-of-care huddles are central to the TeamBirth model. All members of the clinical team meet with the patient giving birth and their support person upon admission to the labor and delivery unit and at regular intervals. Creager says this approach ensures that the team understands the patient’s preferences and condition and is able to establish clear expectations.

“As a team — with the patient at the center — we develop a plan of care for the mom, her labor process and the baby,” she explains.

Every labor and delivery room has a patient communication whiteboard that includes all members of the care team, the patient’s preferences and progress, and the next scheduled check-in.

“The board is a shared decision-making tool,” says Stacy Kovacs, MSN, RN, NEA-BC, Director of Nursing for women’s health. “When we come together, that’s our focal point.”

Although whiteboards in other patient rooms throughout the hospital display information that is primarily useful for clinical nurses, such as the patient’s fall risk or allergies, the TeamBirth boards are patient centric.

“During care huddles, we talk to patients about their preferences,” says Creager. “They may want to have an epidural, have skin-to-skin contact with the baby or breastfeed. Whatever is important to the patient is listed as a preference on the board.”

Prior to completing the admission huddle, the team decides when they will gather again. Huddles routinely occur any time there is a change in the plan of care, after delivery and before moving the patient to the mother/baby unit. They provide a venue not only for patients to express their thoughts, but also for physicians and nurses to air concerns and explain decisions to patients in a way they will understand.

Evidence points to success

“Nurses are key to the TeamBirth model,” emphasizes Creager. “We organize the huddle and rally the team together.”

Although clinical nurses are the driving force behind the model, nurse leaders initially had to create buy-in for the initiative.

“It took a little bit to explain how TeamBirth would change daily practice,” says Creager. “I would hear nurses say, ‘This is what we do all the time.’ I would reply, ‘You explain to patients what you are doing, but you don’t ask them how they feel and if it’s OK.’”

In the past, for instance, a clinical nurse might tell the patient they were going to perform a vaginal exam. Under the TeamBirth model, the nurse might explain that they haven’t done a vaginal exam in three hours and it’s time for another one, then ask for the patient’s thoughts.

“We were able to create enthusiasm for the pilot and reiterate the importance behind it, but what’s really helping us now is seeing the improvements in our Press Ganey healthcare experience scores,” says Kovacs.

In addition to higher CAHPS nurse communication scores, the team improved in these areas in the first quarter of 2023:

• Staff worked together to care for you — Up 11.34% to 88.1%
• Response to concerns/complaints — Up 18.11% to 84.62%

Advancing equity

The overarching aim of the Maternal HealthCARE initiative is to improve maternal outcomes and advance equity in labor and delivery.

“When we learned about the program, we thought it fit with our commitment as a hospital to decrease racial disparities in healthcare,” says Kovacs. “Taking part in the initiative is the right thing to do for our patients and community.” Since joining the pilot, the hospital has taken several steps to ensure equity, including developing an anti-racism statement, offering implicit bias training to caregivers and examining policies for bias.

As part of the TeamBirth program, Akron General is stratifying labor and delivery data by race, comparing the NTSV (nulliparous, term, singleton, vertex) cesarian birth rate of patients. In a few months, when the hospital has obtained sufficient data, leaders plan to examine disparities and develop strategies to mitigate them.

The labor and delivery unit will continue using the TeamBirth model even after the pilot ends in September. Other units in the New Life Center, including the mother/baby unit, have also adopted the approach for continuity of care. Two other hospitals within the Cleveland Clinic health system that provide maternity services, Fairview and Hillcrest hospitals, also plan to implement TeamBirth.

“We are excited to take a leading role in TeamBirth, be part of the change and try to make a difference in the lives of our patients and their babies,” says Kovacs.