SQUIRE Blog

The Heart of the Matter

Susan Mooney

My office is a little quirky.  We have two distinct microsystems that inhabit the same space.  A really small space, I might add.  Two OB MDs and three Certified Nurse Midwives see obstetrics patients in the same building at the same time, yet they function as separate practices.  Same manager and support staff but a different practice style that stems from philosophy.  Our midwives believe in a true midwifery model.  They believe that we, as a society, have medicalized pregnancy.  Their primary mission as care providers is to provide education, support and comfort.  They focus on wellness and relationships.  They spend a lot of time with patients - an hour at the initial visit and then 1/2 hour each subsequent prenatal visit.  They labor sit.  They are firmly committed to quality patient care.

And yet, when I look at the data from the urine culture project, I am perplexed.  The MD service has shown clear and steady improvement in both obtaining and documenting urine culture results.  The CNM service - not so much.  Every time I start to think we are making progress, we backslide.  I have thought a lot about this.  Sometimes, I think I understand what is going on in my office and other times I am baffled.  All of the interventions have been the same for both services.  Many of the support staff are the same.  But, the processes that we introduce morph when the CNMs get ahold of them.  And they morph in a way that negates the effectiveness.  For example, the CNMs don't use the check-out form that the Docs love.  They prefer to just tell the order to their support person who begins to drown in a barrage of verbal orders.  We point this out to the CNMS.  They nod and say they get it.  They keep right on doing it.  We talk about quality and ethics.  They agree with me.  They keep right on doing what they were doing before.  It goes on and on.

I really want to understand what is going on but feel as though I am unable to do so.  Perhaps we do not share a common definition of quality.  Maybe the focus of the CNMs is on other things that they believe to be more important.  Perhaps they see the use of standard checkout forms as less personal, less friendly and unnecessary.  Direct, polite, verbal communication feels so much more human. And yet, a harried support person who is hearing 15 different verbal orders in 15 minutes is bound to make mistakes.  She becomes flustered, stressed and is set up to fail.  She makes mistakes.  The system is unreliable. At the end of the day, I am frustrated with myself that I have been unable to solve this puzzle.  Perhaps I have been too rational.  Presenting data is clearly not the right tactic.  I need to shift gears.  Somehow, I need to make these issues resonate on a emotional level.  I have no idea how to do that...

As I work through this project, I am beginning to think that the real story lies in understanding the difference between the MD and the Midwifery cultures.  There is a lesson to be learned about designing interventions that respect those cultures and work with, rather than against, them.  What works for the medical model that I know so well has faltered in the face of a different mental model of care.  I need to understand this better if I have any hope of achieving meaningful change.