Martha Carlough MD MPH Narges Farahi, MD Siobahn Wulff, RN, C-EFM UNC/Chapel Hill Martha Carlough MD MPH Narges Farahi, MD Siobahn Wulff, RN, C-EFM Intro – Martha, Narges, Siobahn

Disclosures The presenters have nothing to disclose

Family Centered Maternity Care at UNC STRONG clinical faculty (including a midwife and lactation support) with a depth of experience and an integrated MCH service Gradually increasing # of deliveries from approximately 100 (1994)  450 (2015) Partnerships with community practices, a CHC network, a local health department and a free standing AABC accredited birth center Martha

A little history… STFM 2005 The Courage to Bleed: Changing the Culture on a Labor and Delivery Unit Martha Andrew Hannapel, MD Valerie King, MD, MPH Kathryn Trotter, CNM,FNP Warren Newton, MD, MPH The University of North Carolina at Chapel Hill Department of Family Medicine

A contentious, albeit true article published in Family Medicine The “Perfect” Storm Years of growing tension at UNC/CH around FM, OB and midwives practicing maternity care in a shared space A contentious, albeit true article published in Family Medicine A vacuum delivery complication setting off fire works between OB, nursing and FM Martha Helton and Nusbaum. A Birth Crisis. Fam Med 2002: 34(6); 423-5.

Mandated movements towards a better environment Called meeting – Dean, CEO, Chief of Staff and Chairs of OB and FM meet – mandated mediation ($$$) Interim “rules of play” and directive to establish joint CQI and peer review processes Commitment to address triangulation between FM, OB and nursing by expectations of direct communication and professional Principles of negotiation – separate PEOPLE from the problem, insist on objective criteria and evidence that applies to all disciplines, focus on joint interest – healthy moms and babies Martha Needed external mediation because of complex and long-standing nature of conflict, power differentials between FM and OB and need for neutral party What FM learned through this: validation of contribution of nursing to the toxic environment, showed OUR contribution to the problem and the different cultures in FM dept vs. OB department

FM/OB Guidelines Began with the Michigan Guidelines * Started with areas of agreement and progressed to areas of disagreement Confirmed that each department privileges their own faculty and that the “attending of record” is ultimately responsible Definitions of consult, co-management and transfer (Level I – III) established Reviewed and updated annually with key players involved Also include principles of working on L&D and guidelines for communication - MARTHA Berman, et.al. Model of Family Medicine and OB GYN Collaboration in Obstetric Care at the U of Michigan. Obs and Gyn.2000. 96(2) 308-313.

Other Outcomes of Mediation Rapid Review Multidisciplinary CQI – QWIPIC “FYI” notice from FM resident/attending to OB chief/attending on admission of FM patient FM/nursing: Post birth “huddle” to debrief routinely Involvement in collaborative initiatives (low risk birth, introduction of skin to skin, nitrous oxide, continuing education for nurses – ALSO/NRP, nursing conferences) Commitment to communicate with nurses about new faculty, fellows, midwives from all departments Narges

Evolving… Increased collaboration with OB and Peds on quality and safety efforts in maternal and newborn care at UNC NBN Triad and Protocols Mombaby.org Development of an (informal) maternal and child health fellowship in collaboration with UNC OB and a new community hospital partner Narges

Interdisciplinary developments… Integration of perinatal psychiatric services at the Family Medicine Center Revival of lactation services and home visiting program Increased involvement, leadership and visibility of the MCH perinatal nurse coordinator within the institution Siobahn

Women’s Birth and Wellness Center Non-profit birth center with community board, accredited by AABC and backed up by UNC FM The 2nd largest birth center in the USA In 2015, 497 births, 72% at the WBWC 6 CNM FTE, 2 FNP’s and 4 LCs Intrapartum transfer rate DECREASED in last two years, but total births at UNC increased – reflects increasing inductions (AMA, HTN in pregnancy, etc) that are a part of local standard of care Complex Breastfeeding Clinic Collaboration with new Birth Center opening with in Asheville/MAHEC in Jan 2016 www.ncbirthcenter.org Need end of year 2015 stats - ??? Too much to say?

Commitment to underserved Piedmont Health Services (CHC) deliveries – and negotiating this….commitment to underserved in NC and importance of FP’s Integration of newborns from local CHC network into our service as our underserved track continues to develop Continue to care for prenatal patients from local health department Narges

Obstetric Ultrasound Implementation of resident and faculty education for limited third trimester ultrasound Development of expanded procedure credentialing for family physicians at UNC to include ultrasound Development of inpatient and outpatient clinical services at academic and CHC sites – COMPLEX! Narges

How do we teach and evaluation residents in collaboration? We are a team – residents, faculty (MDs and CNMs), nurses from all depts – we equally share in Rapid Reviews, QWIPIC involvement Residents have driven progress in OB US and certification, and are part of our interdisciplinary teams in lactation, perinatal mental health Milestones - www.M3app.org ! Continual feedback/evaluation of our residents (and F3 – they evaluate US!)

Lessons Learned and that we are still learning… Most of the time the system is the problem; people are great to work with Things sometimes have to get worse before then get better There are costs for action and inaction – demands constant attention and communication Backsliding is a danger Trust is hard to earn, and difficult to give Narges

Resources Berman DR, Johnson TR, Apgar BS, Schwenk TL. Model of FM and OB/GYN collaboration in Obstetric care at the University of Michigan. Obstetrics & Gynecology, 2000; 96(2):308-13. Helton and Nusbaum. A Birth Crisis. Fam Med 2002: 34(6); 423-5. Negotiating at an Uneven Table: Developing the Moral Courage in Resolving Our Conflicts, 2nd edition, Kritek. Getting to Yes: Negotiating Agreement without Giving In, 2nd edition, Fisher, Ury and Patton. The Prince, 2nd edition, Machiavelli. Translated by Mansfield. www.ehcco.com - Conflict resolution in clinical care

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