Grow Midwives Webinar Follow-Up: Integrating Midwifery-Led Maternal Healthcare

April 26, 2018

Grow Midwives Midwifery-Led Care a 360 exploration


On April 12, 2018 Ginger Breedlove hosted a webinar that explored many of the tools available to midwives that can both help create a new practice or better an existing one. If you would like to consult with Ginger or any of the other Grow Midwives team, reach out on our contact us page.

If you would like to follow along at your own pace, Ginger’s Prezi can be found here.

Ginger: [00:00:03] Well I'm going to go ahead and get started and we'll let people join as they come sometimes when we have smaller groups it's nice to do just a short introduction if you're willing to do that, so you will have a little bit of an idea of who is on. I do want to let you all know these sessions are recorded and transcribed, so it's helpful to put your microphone on mute unless we have sort of an open mic going and I intentionally built in time to talk in this session versus waiting until the end which we typically do. Sort of built into looking at three different products and having time to talk about each one of them a little bit. So if you're willing, I love for you to introduce yourselves. Regina, I'll just start with who I see at the top in front of me.

Regina: [00:00:53] All right I'm Regina Taylor as you and I were talking, I am a brand-spanking new graduate from Frontier Nursing University and just passed the certification exam yesterday. Very excited about my job search and to start practicing

Ginger: [00:01:17] Congratulations. We need more midwives. It's so wonderful to hear hear you're part of the team.

Regina: [00:01:23] We do. West Tennessee is sorely lacking, but I think it is improving. We're finally getting more in the Memphis, Tennessee area, but right now Jackson Tennessee, which is where I'm probably about 45 minutes from has two midwives and it's a huge city, so it's just crazy.

Ginger: [00:01:48] Well, hopefully you'll learn some things tonight and hear some discussions that'll give you some ideas. It's great. Barb?

Barbara: [00:01:57] Hi I'm Barbara Hughes. I'm a nurse midwife from Denver and have a private consulting practice and was honored to be invited to be an author for one of the tools that Ginger is going to be sharing, so I love everything about the business of midwifery and have been part of the Midwifery Business Network for quite some time and I'm just finishing my term as Business Section Chair. So I'm excited that all of you are on this webinar and looking forward to hearing your feedback about what you are going to learn from Ginger who is a mentor to all of us.

Ginger: [00:02:33] Actually we're going to learn from each other. So thanks Barb so, so glad you're on. Jody? You're on mute, Jody.

Jody: [00:02:50] Frontier, Frontier graduate from '96 mostly worked birth centers and home birth.

Ginger: [00:02:56] And lives in Kansas.

Jody: [00:02:59] Kansas. Yes, sorry.

Ginger: [00:03:01] We're down the road from each other by about an hour.

Jody: [00:03:06] Ginger was one of my midwives with my first baby.

?: [00:03:10] Sweet.

?: [00:03:11] Wow.

?: [00:03:23] Melinda?

Melinda: [00:03:24] It wasn't letting my mouse do the trick, so I had to use my keyboard. Melinda Hoskins I'm a Frontier grad too from [cross noise] I told everybody when I first went to midwiferybound that we're gonna have to change the laws in Nevada and I've been at it ever since. I'm currently in the process of trying to get a birth center started. The latest go-round is the potential landlords don't think that my husband and I make enough income to take on the debt that would be involved in building out a birth center. So somebody suggested I should go and try to figure out how to do an FQHC.

Ginger: [00:04:10] Oh My.

Melinda: [00:04:10] And I'm looking at the options. I don't know.

Ginger: [00:04:19] Hang tight, Melinda. Something's going to break.

Melinda: [00:04:21] I keep telling myself.

Ginger: [00:04:23] It will.

Melinda: [00:04:23] I think it might be me.

Melinda: [00:04:26] No, I don't think it's going to be you. And that break is a positive one. Thank you. Hey Sherilyn. How are you?

Cheryl: [00:04:34] Hi, I'm good. I'm Sherilyn Gibbs and I live in Hamburg, Pennsylvania and work in Allentown at Lehigh Valley Health Network and I'm the director of midwifery services there and we are in the process of growing midwives in the network in their five hospitals in the network. And so it's quite a big task.

Ginger: [00:05:02] Yeah, it's a big task.

Cheryl: [00:05:04] I will tell you that Ginger here did grand rounds for us just a few weeks ago and that was the first grand rounds on the topic of midwifery and it was quite an historic event and a lot has happened since then, Ginger. We'll catch up some time.

Ginger: [00:05:22] Great. That's great to hear. Well, maybe some things will spark in the conversation tonight. As I shared earlier I'm not sure if you've heard yet, we have Barbara Hughes on who was a major author in the new PBGH product that was released that is quite complementary to the other products that we're going to talk about tonight. So let's let's get rolling. That is not where we were going to start.

So let me see what my problem is here. Just back it up. See if I can hit the start button. There's one thing about Prezi. It's getting used to how you use it. Where do you start is often the question of the day. So there we are. Topic one. Where do you start in this conversation? And it can be immobilizing sometimes. How do you think about integrating midwifery? Most of you on this call are probably in situations where it's not where you want it to be. We probably wouldn't be on the call or you're not feeling the need to modify or in some way adapt a current practice that you're in.

I know there are amazing successful midwifery practices in a variety of settings in our country. It's not like it doesn't exist. But personally I would say that it's not the predominant experience of most midwives.

There's always an opportunity to try to sort of expand the scope or improve the understanding of those that work with you or around you where they can consult with. And, for me, it's always an opportunity to sort of look at how can we expand education and awareness.

So thinking about the team and type of practice is is a really where you need to start. Is this a conversation that you want to focus on. That's solely ambulatory where you're only really contemplating working in a clinic-based setting and not knowing full-scope practice which many midwives do.

Are you thinking about how to integrate midwives in a free-standing birth center? Thinking about integrating midwives into the community hospital which is extremely different from integrating midwives in a very large academic teaching setting. So being able to identify the type of practice that you're interested in navigating really does have an important place in how you figure out the starting point.

You can take some shortcuts with the less burdensome, less large institutional settings that might get you to sort of your goal earlier than if you're at Lehigh Valley where you have however many hospitals that has layer upon layers of processes by which things have to be approved. So suffice it to say that you being able to conceptualize and put on a piece of paper what that is what you see that ideal being is what I think is a good guidepost to get you going.

So we're going to start with the American College of Nurse Midwive's most recent publication of the administrative manual for midwifery practice. This wonderful book here doesn't have many pages, but when I started the first midwifery practice in Kansas City at a hospital at St. Luke's on the plaza the manual literally was, I would call it my Bible, with the most respect. I used it every day.

There were things that I had no idea. It was uncharted territory for me and the book really was my way of trying to have a blueprint for what I needed to do. The beauty of this book is that it's been authored by people like Barbara and Joanie Flager and others who have been in leadership positions in a variety of types of midwifery practices for a very long time.

It came out of what used to be called what was it, Barb, the business? The service directors network. I think that was the name of it. At the time of their heyday, I was on the academic side as a educational program director. But these two groups the directors of midwifery education and the service side which tended to be the practice directors, of chief midwives of the practices around the country would meet twice a year and talk about issues related to the world of clinical practice and the integration of students.

With all those issues you can imagine especially for Regina just coming out of an educational program how hard clinical sites are for a lot of people. So with this being the fourth edition, this has been around for a while and still is, I think, a critically important document to guide the midwifery model and if you watch the PBGH webinar prior to coming on to this, which we hope you will do you will see referenced in their documents. And Barb, I think you did that with beautiful intention how these products [noise] each other. I don't think you'll get the benefit of the PBGH work without having this manual beside you. They are not mutually exclusive. So what I think you hear in this picture was what I think is a really great place to start.

And that is that is Chapter 2, developing a business plan for a midwifery practice. It's your roadmap. We've done webinars on this before kind of the community assessment, the general idea of what your budget is going to look like. Many of you have been, all of you who have attended Frontier, have had to attend How To Start A Birth Center all those concepts about business that are taught to varying degrees, but not comprehensively in midwifery school are sort of outlined for you pretty well in Chapter 2.

You may find ideas that you haven't really thought of around you that you will definitely be given information on how to think about what your business is going to look like. So, for me, when I left the Topeka Birth Center were Jody and I worked together, I went to start the first Hospital-based midwife service in Kansas City in a tertiary care setting and, Sherilyn, to some degree like you, I had never done that before. Right? And all I had was asking my friends and this book. I certainly wasn't going to show my ignorance as the first midwife the system ever hired, that I didn't know what I was doing, even though I was nervous a lot. So I would say go to Chapter 2 first. I'd love to know how many of you already have this book that are on the call. Sherlyn has it. Melinda has it. Jody.

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Barbara: [00:13:00] Ginger, I just want to make a comment. Sherilyn was the primary author on the chapter that I worked with her on on marketing. I didn't know that. I haven't looked at it recently. So I don't want to belabor this a lot. But it's fantastic. I really wish all midwives had this book whether they were going to be a service director or not. Because I think part of what challenges us is all midwives not being business savvy even if you're not leading the project you still need to understand the conversation. The importance of certain components.

And, in order for people to be transparent, it has to be understood right? You can't come back and say, "You didn't tell me about that." So let me just read you again the title of the chapters to again, sort of solidify the role of the service director. So you know I've been consulting enough now since November that some people, even in job hires are going to go work for people and not be defined, number one, as a service director or see these salary differentiation. That's an incredible amount of responsibility. And I think that chapter really does help begin to visit the job description, bring that up for you, as well as validate the tremendous amount of work that goes into that job. While you may be doing clinical as well and all the other things that are represented within the institution that you have to or should be a part of. Developing a business plan, successful grant writing which is a chapter that I wrote. How can you generate revenue that perhaps can come from non-billable services. I will tell you that 10 years or so working at St. Luke's I probably brought in close two and a half three million dollars worth of grants that really made the hospital like us. Very, very helpful also in using funds in a way that you want to direct. If you can. There's a chapter on office management and what do you need to have a healthy functioning office environment. How does an office work. What do you need, your supplies, education materials. All kinds of things about taking the people in and putting them in seats in a setting. The chapter Barb mentioned on marketing and communications. And I now remember that Sherilyn that was part of the [noise] project I think. Am I right? You're going in the dark on me right now. There's a section on billing and coding that I believe Joanie Slager the editor of the book wrote. And, of course, if you ever have an opportunity to hear Joanie speak, you will never walk away without learning another new way to bill and code and the incredible responsibility that you have for doing that correctly. There is a section on human resources, a section on legal issues that my husband authored, a section on credentialing and how do, for you Regina, how to prepare yourself now for being credentialed in a hospital. There's no reason to wait. There pretty much templates. It's a shame. We don't have universal credentialing in our country but maybe someday we'll get there. Everybody pretty much wants the same things. And so there are ideas of how to get prepared for that. Really important section on quality improvement data collection definitely talks to you about ACNM benchmarking and why data drives decisions. Before you touch your first patient, if you're starting a practice, I would urge you to figure out how you're going to collect data that maybe the hospital collects and maybe midwifery specific that you're going to have to figure out how to collect on your own. But critically important to validate that your quality, your outcomes, patient safety, cost efficiency, and all those things that are the drivers now of what helps keep midwives in practices. A section on precepting students. And then some pretty great appendices in the back that are tools that are sort of templates for you to be able to work from. So what I'd like to do in this next section is just take a few minutes to see if you have any questions about this manual, how you've used it, anything that we can talk about as a group for a few minutes that relate to the specificity of this manual in particular. You're not going to find in any other textbook for our profession. Any thoughts? Anything resonate with you? Any successes that you want to share

Melinda: [00:18:25] I just say I have been very grateful for this manual. It's been very helpful in terms of being able to answer questions for people and it's great.

Ginger: [00:18:40] One thing I might ask you, Melinda and others, and I haven't attended a how to start a birth center workshop in a very, very long time. That probably was when the first preceptors were trained of in the chicken coop with [noise]. This is one of those people. Can you talk just for a minute, any of you, about how their manual on how to start a birth center may compliment or also overlap this manual.

?: [00:19:12] I took the workshop a second time in November of 2016. Once we had regulations on their way to being where we could could open a birth center and one of the things that to me is really valuable from that is the excel template, templates for doing projections and things so that it is very helpful in terms of getting your numbers in and looking at what numbers do you need to have. When I've shared that with other people the bank the other advisors, and stuff they've been just massively impressed. Wow. Other businesses ought to have this kind of thing. Then the other thing that comes with that workshop is a sample policies and procedures manual which is basically the Redding birth center.

Ginger: [00:20:07] Yeah. Yeah. Great. Any other comments? Things that you have found valuable from this manual?

Barbara: [00:20:22] Ginger, it's Barbara. I just want to reinforce that when one of the other tools you're going to be talking about, the integration guide, was conceived and there was so much valuable work in the administrative manual that it did not make any sense to duplicate it. And I think it helps when people within organizations where we're trying to establish a practice or grow a practice that want to see a national resource and this is the first time that ACNM actually published. This document had been through the service director's network and the midwifery business network. And so I was really thrilled that it is now part of the ACNM family of tools. And I think that gives it additional credibility and value.

Ginger: [00:21:17] I completely agree with you, Barb. That's why I think every midwife should buy it. Sherilyn?

Sherilyn: [00:21:24] I was wondering if there is anything in here about hospital privileges. I know credentialling, hospital credentialing is here. I haven't looked through that section, but that's what we're working on right now is I think we were kind of talking about that when you were here. And I and I really pushed that since your presentation, Ginger, and our chief told me the other day that he is going to push try to push that through the by laws, because they are going to have to change their bylaws. I just wondered if there was anything that would be helpful in here about that. Do you know?

Sherilyn: [00:22:06] I'm looking at the appendices now and anybody who knows for certain speak up, but I'll tell you one of the things I have done recently when people have asked for some help on this, and you'd be surprised what you find on a Google search is to type in, "CNM privileges" and watch what pops up, which is going could be an amazing array and a variety at the same time a hospital which lists - both from teaching hospitals as well as community hospitals. I think you will find it almost a universal privilege list with the additions of things like first assist, which is typically an added procedure. Some midwives seek vacuum extraction. I had one just this week seeking privileges to do breech and multiples with the physician in-house. Those are typically the outliers. But, in general, I think you're going to find that all the privileges for the nurse midwife look pretty universal. I would just caution, and then Barb jump in, that you should not dictate ambulatory care practices. That's only pertaining the hospital privileges. Even if you're a hospital-run service, which we were, our privileges only remained oversight of what we did when we were taking care of patients who were admitted in our hospital.

?: [00:23:42] Sherilyn when I started the St. Anthony midwifery practice which that hospital no longer does OB. So it doesn't exist. I really wanted to make sure that midwives had privileges were we're credentialed as full members of the medical staff. So I put together a notebook for the credentialing committee that laid out the business case and the items were current at the time and was asked about that so often I actually shared all of it with ACNM. And if you just do a search on the ACNM Web site, you'll find that whole notebook and it's organized so that it starts with, you know, basic definitions of midwifery what's the scope of midwifery practice. And I put it together in a very logical fashion so that by the time I walk through the whole document with the committee they said, "Well, we don't see any problems. Sure we'll approve this." And then they took it to the board and the board approved it and we were credentialed as full members of the medical staff.

?: [00:24:46] So you have admitting privileges as well as regular credentials that we've been talking about?

?: [00:24:55] Yes.

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Ginger: [00:24:55] I think that the difficult things to figure out is what is believed to be true and what is reality with state regulations related to the scope of the midwife. Right? If you're in a state with a supervisory authority, the language might be very different, but for me in the state of Missouri we were not required to have that kind of supervision. And not only did we discharge the mother, but we admitted and discharged the normal newborn. So we had couplet care in our practice for 10 years. So that's one issue. The other is I really urge that we start thinking about getting temporary privilege or guest privileges until we have permanent privileges, which is what a lot of physicians do. They can't wait for four to five months to start seeing patients and delivering them. Why are they making midwives do that? There's really no reason that you can't ask to have temporary privileges and start seeing patients in the hospital, but a lot of people don't think about doing that.

?: [00:26:08] Ginger, back to a comment that you made about just before we got on to this. You said something about the privileges do not. They should not include ambulatory.

Ginger: [00:26:22] Right.

?: [00:26:22] So, ours do. And I asked about that and they said, "No, that this network requires that to be in there" and that didn't make sense to me. But I didn't fight it seems very strange.

Ginger: [00:26:36] Yeah, I think what you're going to have to do is educate them. And, so my first question very gently to the right person would be, "Do you..." So if they have hospital physicians that are [noise] Do they approve all their ambulatory care practices?

?: [00:27:03] I mean, I don't know.

Ginger: [00:27:04] I doubt it.

?: [00:27:05] I doubt it too.

Ginger: [00:27:06] So it's a matter of sort of trying to be an equivalent to how other credential providers are treated. You may have a different scope of care, but you certainly should not be monitored in the ambulatory world when no one else is.

?: [00:27:30] Ok.

Ginger: [00:27:30] Melinda?

Melinda: [00:27:30] I'm going to say one of the, you know, we have full scope authority practice in the state of Nevada. But what we're dealing with with the hospitals and the insurance companies is they're saying that something about their accreditation is requiring that they require supervision for us in the hospitals and to be credentialed with the insurance companies.

Ginger: [00:27:56] You know, Melinda, you were Joe's call on vicarious liability.

Melinda: [00:28:00] Yes, I was.

?: [00:28:00] You all are teetering on a restraint of trade case and those take years.

Melinda: [00:28:06] I keep thinking and getting old enough to pursue one of those.

Ginger: [00:28:11] And Joe offline when we were done was basically talking about that. I think you may be facing people saying things to dissuade you from persisting. You know that's just a first blush, because there isn't anything regulatory that that stands on.

Melinda: [00:28:33] Yeah. It's seen as being, you know, this is what the legislators told me. It's seen as being, the businesses have the right to do what they want to do unless we put something into law that says they can't do that.

Ginger: [00:28:50] So what I would say, and then we will move on, is survey the rest of the midwives in your state. See if you can find a precedent where someone has succeeded. Have some meetings with them. Find out the physicians, the papers, the midwives. See if you can find that practice and then you've got a little more ground to go forward in conversation.

Melinda: [00:29:18] So far as I know there isn't one. [noise]

Ginger: [00:29:27] We know you're trying. There's so much to do. There's so much there. The next resource I'm going to take you to is the ACOG collaboration and practice guide on implementing team based care. I'm going to drop you to their site right now. That was the year-long project of Dr. John Jennings and I'm just going tell you a little story, because Dr.Jennings is an absolute supporter of midwifery. All midwifery that is ICM approved. When Dr. Jennings was elected, they'd get a one year term and he wanted to get a million moms on the mall and created a powerpoint he showed me several years ago called The Big Hairy Audacious Goal is BHAG. He presented it before the ACOG board and staff and they said, "No, you can't do that." And this is what he ended up doing which happened to be during my time as president was working on collaboration and practice with a second tier coming out of that into professional education and this collaboration and practice team based toolkit from ACOG has been downloaded more than just about any other recent tool. I see you smiling, Barb. It is a tremendous, again, association document that has helped validate midwifery on a national scale and what's really fantastic about it is it's 20 some organizations, I'm not going to belabor us here with who they were. But a task force that was multidisciplinary. It truly was a product of people sitting around a table together creating the chapters, writing chapters. Our two midwives that were on this: Kathy and Maryann actually led two the work groups that produced chapters and it is really a great guide post to bring out of the closet or to hand to someone who is an OBGYN who Honestly may not even know this document exists. One of the profound things that I have learned especially being around national-level conversations is things may be be said at the national level, but sort of like translational research, to get it to the humanity level for it to be implemented is a completely different story. But sometimes in our profession and in ACOG and with CPMs, all of us. We don't know what we don't know. We're so busy we don't know what documents exist out there and we simply just haven't taken the time to think about the content. And it can be an unfortunate roadblock. But there is a wonderful executive summary here that talks you through what the 60 some page free resource is. And I would really urge you to be aware of its existence. There are some favorite sections that I'll give to you in just a minute that I think are great as leading concepts within this paper that can get you some traction pretty quickly and I'll share those in just a minute. But I would love to know if any of you know about documents, if you've used the document you have any success with it. Hi, Pam.

?: [00:33:20] Ginger, I'd just like to reinforce what you said. In fact this document is one of the resources that we use throughout the midwifery integration guide and there's a link to it, so people can actually go directly to it and being able to define what does "collaboration" mean and value the contributions of midwives as well as physicians is a great way to build that trusting relationship which we know is critical in clinical practice.

Ginger: [00:33:54] I think the other thing this document did, which is carried forward by PBGH is this concept of team-based care. It goes right in line with the ACOG joint statement that midwives are autonomous independent providers within a team. So it begins to tone down, Linda, that concept of supervision. In fact, there's less vicarious liability if you are practicing right. We just had that lecture. So this concept of team based care is really carried through this document with examples. Others? Sherilyn, have you used this?

Sherilyn: [00:34:37] I haven't. You talked about it in the presentation that you did. And that's one of my goals is to start digesting it.

Ginger: [00:34:49] Yeah, again I'm going to give you my favorite sections of it here in a minute. Regina, did you learn about it in your program?

Regina: [00:35:00] I do not believe that we did. I do not remember referring to that at all.

Ginger: [00:35:08] So as a new graduate, someone going out seeking employment. One of the benefits of you knowing about this is to help you frame what is an endorsed model of how midwives and physicians should be working together. I think the more informed you are when you go into those interviews when you would ask people about the practice model and hey did you know about this and this is really you know a great thing to hear more about your interview. Lots of lots of great ideas.

Regina: [00:35:42] That's what I was already thinking about that this will be a great resource to start helping me prepare for interviewing.

Ginger: [00:35:49] Yeah

?: [00:35:51] Is this available or is this behind their... you've got to be a member?

Ginger: [00:35:56] It's FREE. Freely downloaded.

Regina: [00:35:59] That's awesome.

Ginger: [00:36:01] Yeah.

?: [00:36:02] In North Carolina, we've given all of our legislators a copy of this.

Ginger: [00:36:06] Great idea.

?: [00:36:07] To educate them about what collaboration really means with us working with OBGYNs.

Ginger: [00:36:15] Yeah, I have a little bit of experience for some OBGYNs in North Carolina. I actually have an RN license there [crosstalk] was a good example for me not working with them as a clinician. But in a different role to understand how much they really didn't know. What does the word "collaboration" mean and what does my, meaning the ACOG actual organization think and when we started talking about it, here's my favorite sections. Chapter 1, Chapter 2, and Chapter 4 with the page numbers there for you. They were like, "I didn't know that." You can be a member, but it doesn't mean you're up to date with what's said by your professional association and I can't fault people for that. I remember years when I was such a busy practitioner. I barely had time to take care of my four little kids and run a practice, but I think if you can strategize about how you use the document. Not: here, read it, you need to change, but sort of engage in what this could bring to the relationship that is of value to them. They're much more willing to listen than to feel like they're doing something wrong and they're supposed to figure out how to fix it. We all know that, but it doesn't work that way. But the rarely used resource part I think is both for both professions, Barb.

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Barbara: [00:37:49] I would just like to reinforce the value of knowing what ACOG's positions are. And that's really applying to become an ACOG educational affiliate. When you can get to even the members only section and use that information as you're building relationships with physicians. Again, it gives you, I think, an added air of legitimacy. So, yes, we all want to be ACNM members. We want to encourage all of our colleagues to as well. But I think having that ACOG affiliate membership is extremely helpful.

Barbara: [00:38:28] I'm just putting in a plug right now for the national women's health [noise] currently has special where it's half price a ACOG membership.

Ginger: [00:38:41] They're kind of circulating that around. They've done that for ACNM once I tried to get them to just leave it open because what Barb said is exactly what I tell every single person I talked to. Go be an educational affiliate member. Because of the value it brings you. But they have not cracked on that one yet. We'll see. Absolutely so any other pearls Barb or others that have used this that you would like to share before we move on to the PBGH products. This is really, really valuable Sherilyn. I think there are sections in this that even some of the residents could learn from like another kind of, I don't know if you know any kind of reviews that aren't necessarily grant rounds that are a little bit smaller in nature, but helping all staff understand what team-based care is which they saw just a very little window of a few weeks ago. This is the entire guide to what that presentation was. So let's move on to the new and amazing work that Barbara, I don't know If you and Jenn were the primary authors, but certainly the whole book is written from a midwifery lense. Barb, why don't you say about why and how did this happen?

Barbara: [00:40:16] The Pacific Business Group on Health, which is an organization out of San Francisco who's very interested in improving maternal child outcomes as well as safety and cost effectiveness in health care, has been really focused on midwifery for the last number of years because they truly believe that midwifery is the answer. And they applied for grants and got a grant to develop a document about, basically they first called it the playbook for bringing midwives into a hospital or practice organization. And I didn't like playbook and there are lots of toolkits around. So we called it the midwifery integration guide and so they're PBGH and you can just go to their website and it gives you all of this information. They are a California-based organization and their funding came from California. So one of the things you'll notice when you review the integration guide is it talks ,  I made as much language as we could fit in to be midwife neutral. But there are places that it talks about CNMs, because California only has CNMs. So when you go to their website you'll be able to register and really it's giving your name, what you do in a practice, and your e-mail address, because they want to monitor who's accessing the guide and be able to do follow up with people, so you can go on the PBGH Web site and just click on download and they will email you within seconds a copy of the guide. So their request was a 10 to 20 page document. What we have is a 50 page document. They brought in a wonderful graphic designer. And there are twenty five appendices as well as links to so many of the things that we have already talked about. So, Regina, when you're looking at starting a practice, there's information about what are the core ACNM documents. Sherilyn, when you're talking about privileging, the core competencies for midwifery practice are a key one and if those can just be woven in as the organizational guide and then people with additional skill or education and certification and things, like C-section first assist, those can just be add ons and it makes it very simple. So the guide was designed to be used by people like all of you, as well as CFOs of hospitals, leaders of physician practices. The two things that the two areas in which PBGH has not evolved to yet. Because in California there is supervisory language, the midwives must be supervised by physicians. There's really not any discussion about birth centers or home birth and we feel like ACNM has all the great resources you need for home birth and AABC for birth centers. So I'll really be excited for you all to download this and just dive in and start taking a look. And it starts right from the beginning of, "So you have a dream that you want to start a midwifery practice." Where do you start? How do you, Regina, go to some key decision makers in an organization if you're going to start to practice from scratch. What do you want to ask of them. So it's just a very concrete where do you start all of the steps including collaborative practice. And then how do you monitor the practice for success. That includes financial success as well as monitoring clinical outcomes. So as Ginger is scrolling through it gives some basic information about CNMs in California. Again, this was funded in California. PBGH identified and interviewed a number of midwifery practices and included interviews of the physicians and the business leaders in the practice. And it's basically also walks you through how to develop a financial pro forma. One of the other tools that PBGH commissioned at the same time this one was commissioned as a great tool called The Financial Tool and it was designed by Milliman and they were actuaries who designed this tool, so you can download the tool. It's an Excel spreadsheet. Some of the settings are prefixed like the revenue generated by Medi-Cal for obstetrical care. But then you could also customize how many hours does a midwife work? What's the midwife's salary? What are the expenses? And then you end up with a pro forma for the cost and profit generated by one midwife FTE. So you just go through them one midwife at a time and if you're compiling a practice then you're just going to compound them or you're going to change some of the settings. Actuarials tend to be extremely conservative and they want to make sure you understand, you know, you can't sue them if this doesn't get you the kind of practice results that you want. So they have a couple of places that you have to agree. But it's a beautiful tool and very easy to use.

Ginger: [00:45:56] It is not opening for me right now, so I am not going to that section. You know, I think what was astounding to me having been very familiar with the other two products you heard about tonight is how these products really come together as one functioning unit that can guide you in a much more sophisticated way than just using the service director's manual or the new administrative manual that we talked about in the very beginning. I think the robustness of what's there, the level of validity that  Pacific Business Group on Health brings to the conversation. Again, Melinda, I'm thinking of you in particular to condense this in some way and be able to present it either to the business world or the bank or to the hospital could be another.

Melinda: [00:47:03] My mind is racing.

Ginger: [00:47:05] Yeah. Yeah. Did you know about this before tonight?

Melinda: [00:47:10] I had heard something when you guys did the other web presentation that I hadn't had a chance to look at that. So now this is new to me. So it's going to be wonderful.

Ginger: [00:47:21] You will see a video here that starts out with Dr. Shaw and I talking for maybe 12 to 15 minutes. The remainder of the hour is Barbara and her colleague Brynn speaking about the product and really an introduction to it that I think really is great to watch before we tackle all the information they compiled, which is a massive amount of information. I think you could get a little lost and overwhelmed. But honestly if you didn't watch the video first part.

Barbara: [00:47:58] I totally agree, Ginger. And, again, we tried to design it so it can be helpful not only for starting a practice, but if you have an existing practice and you want to reset the culture or improve quality outcomes, it gives you, right at the beginning, some guidance for what sections you want to go to.

Ginger: [00:48:21] Right. Right.

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?: [00:48:25] I have a question where you can get RVU information. So in our, in our network RVUs of course are the big deal and they look at how many each provider is producing and that's how they kind of judge your worth or revenue that you're bringing in. And I think that's probably the case everywhere. But it's hard to find information about how many RVUs are attached to different things that we do in the office or, you know, how many we get for a delivery and that kind of thing.

Ginger: [00:49:13] Melinda, do you have a response?

Melinda: [00:49:14] I'm trying to remember the name of it, for a while in my husband's practice we were using a coding tool. It's an online. You have to subscribe yearly. It has all that broken down. It's all there with Medicare numbers for for reimbursement and stuff, but it was really helpful to me and I discontinued the eight hundred dollar subscription, because I didn't need it for my home birth stuff, but, every once in a while, I think I need it for a month. I need to go back and look at those codes. I have most of the RVUs from my home birth practice and the birth obstetric related codes and stuff.

?: [00:49:58] So it is hard to get your hands on it if you don't have a subscription?

Melinda: [00:50:03] Yeah, I haven't found another source that is not subscription but...

Ginger: [00:50:10] There are many online companies that sort of cater to this. There's a post that I made a few, maybe months back now on ACNM Connect about just what is an RVU and how is it measured actually somebody's masters thesis, I believe, is what brought it up. The frustrating thing for me about all of this is how does it really relate to salary? And this is sort of written into the medical physician provider world, not in the advanced practice provider world and we are presumably being judged on our utilization and patient acuity and ways that are not equitably measured. So if the argument could be made, Sherilyn, if they are going to pay you on RVUs based on the model physicians are being reimbursed by. You need the same support staff. You need a higher base salary and you need to be treated equitably in that conversation. And they're probably going to say, "Well, we're not going to do that." To which my answer would be, "Then don't measure me on RVUs." Mesure me on other productivity variables and let's define what those could be. I think those are, correct me if I'm wrong, Barb, those could be measured with some of the tools PBGH is providing you in that financial analysis portfolio.

Sherilyn: [00:51:44] Absolutely. And one of the other things that PBGH produced is a white paper that talks about the financial tool that gives a nicely condensed yet broad overview of the value that midwives bring. Yes, there's value in numbers. We know that, but there's also value in quality of care and good outcomes. Value in patient satisfaction. Value in being able to draw new patients to a practice or a hospital. So I would encourage you not just to go to the Excel spreadsheet, but actually read the white paper and we have that as one of the appendices in the integration guide. But you can just download it directly from the PBGH site.

Ginger: I f they want to integrate midwives fully Sherilyn, then they need to understand the midwifery model is not the same as the medical model and you're going to help them understand that.

?: [00:52:45] You're going to have to work hard to get that to happen, because they don't have a clue.

Ginger: [00:52:49] Well, that's okay. That's better than total resistance which is what Melinda's facing right?

Melinda: [00:52:54] Exactly.

Ginger: [00:52:56] It's like raising your kids: the ones who want to learn and the ones that are so stubborn they walk away from you. They are just different challenges that you have to figure out how to work through. So we talked, we're about at the top of the hour, so we talked a bit about this. I am thrilled, Barb, that you were on and the listeners who will be on and listening to this later and for the opportunity really to sort of hear from you the origin and the incredible value of that tool kit. I really think all of you need to have that right beside the other two documents as you're navigating. The other resources I want to tell you about we have mentioned.

?: [00:53:41] May I just say something, Ginger?

Ginger: [00:53:41] Yeah.

?: [00:53:41] Barbara, thank you for this material. We still teach midwifery roles courses in our program at East Carolina University and the second role's course that our students take is more of a high level integration type of roles course and they have to create their own business plan for this course, so this material is just excellent. Thank you so much for sharing.

Barbara: [00:54:05] You're welcome. One of the appendices is actually a template for a business plan that a midwife in upstate New York developed and Brynn almost wanted to pull it she said, "It's so deep." I mean there's just tons of content there. But, boy, would that be a great resource for your students to be able to go to and see a business plan that was actually used to start a new midwifery practice in upstate New York.

Ginger: [00:54:35] Absolutely.

?: [00:54:36] Very exciting. I've already shared it with them, with my colleagues.

Ginger: [00:54:36] You're going to have to change the assignment for them. Like, actualize it before you graduate. Just remember, AABC is out there and that training really can be helpful for private practice as well as starting birth centers. I've popped this website up just as a resource general over arching view of what does it take to start a practice. Granted it's a medical practice, but in all reality what we're doing is a mini model of a medical practice and I think that for those who just don't have a clue, maybe those students who don't know where to start, it's a great website to look at. The other thing I really want to promote is the ACNM Midwifery Works, which is every fall. This year it's in the beautiful, I'm guessing beaches, of Fort Lauderdale, Florida. An amazing experience to go and network here. Presentations on all those topics that are relevant to having a successful, sustainable practice. They are still accepting abstracts actually if any of you are interested in presenting something and I do wonder sometimes, Barbara, if it wouldn't be great to have, I'm not going to be there, but somebody can pick the site, if you think it's worthy. Have three practices that are struggling, like three case studies of three practices. Put them up on a panel. Talk about what the struggling is and get some group help out of that session that ends up helping everybody as mini case studies. Instead of always hearing from a total expert that has already figured out all the problems. A couple thoughts to leave with you. Critical steps and actions to move a strategic plan from a document that's sitting on your computer to actions that actually drive establishing a practice. It's often what hold many of us back is taking your dream and putting into reality can be so overwhelming. You Really need to find a supportive network and that could come from a variety of places, but to try to hold on alone trying to actualize a business development is a very difficult thing to do and business knowledge is fundamental to your success, which is why these tools are really, really there for you and very valuable. So I want to leave you just with sort of why we're here and what we're helping with and Barbara as well is really helping you build those relationships and trying to find ways to integrate best practice for midwives in a variety of settings. We're actually going to be exhibiting at ACOG in Austin. I think we may be the first midwives to exhibit in the ACOG hall. It was pretty tough to get that to happen and believe me, Barbara, if this document or little cards or something about PBGH we want to continue to distribute those as a tool to continue to educate what can often be our biggest roadblocks - finding providers who will work with us. So what I'm going to ask of you, as if you don't have enough on your plate is any desired topics you're interested in. We may do a survey here before long. We'd love for you to share the Web site. We'd like to know if we can help in any way. Certainly love your help in growing our Facebook page and raise awareness about the Web site. That's all I have. So thank you very much for being here. It's great to see people return and it's great to see you all still smiling. Lots of longevity here, Regina, you probably have a total I don't know. Thirty, Sixty, ninety, hundred twenty years of midwifery experience in front of you. It's pretty cool.

?: [00:58:59] Excellent job Ginger thank you very much.

Ginger: [00:59:02] Sure, thanks. Have a good evening everybody, goodbye.

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