It's 22 and a half hours into a midsummer Thursday, and the pace has suddenly quickened at Parkland Memorial Hospital in Dallas, the busiest maternity hospital in America. A woman named Sanchez has been in labor for 21 of those hours, and she thinks that the baby might finally be coming. With the passionate coaching in Spanish of nurse-midwife Marta Correa, Sanchez pushes mightily, in absolute silence, for an hour.
The baby's heart rate looks healthy, and he tolerates the pushing and attention well. He just doesn't agree that it's time to be born. "He seems really content where he is," says Dr. Pauline Petrovski. "Up in Canada."
If Baby Sanchez is holding out too long, a couple of corridors away, another Baby Sanchez is determined to arrive all too soon. Baby Sanchez number two — only 27 weeks along — is being born just moments after his mother was brought down from a hospital room where doctors hoped that bed rest would allow the pregnancy to continue. But Baby Sanchez number two is insistent. He tumbles into a brightly lit delivery room at 10:39 PM, a room crowded with 13 people other than his mother, including three pediatric staff members from a resuscitation team. At a pound and a half, he's small, but he squalls reassuringly. A portable incubator — the blankets alone seem to weigh more than the little boy — stands by.
Just as the premature baby is being born, the intercoms throughout Parkland's labor and delivery (L&D) rooms squawk, "Stat C-section in OR 2! Stat C-section in OR 2!" — and controlled pandemonium ensues. Outside the delivery room of Baby Sanchez number two, a woman on a bed speeds past, surrounded by doctors, nurses, and technicians, all running nearly full-out.
A "stat" C-section means that something has gone wrong or might be going wrong, and doctors want to get the baby born as quickly as possible. The stat is called at 10:41 PM. Within two minutes, the mom is in OR 2, along with 14 medical personnel in blue scrubs, all of whom know exactly what to do. Two young surgeons — Ike Rahn and DeDee Bingham — are scrubbing their hands and arms furiously. "Have you ever done a stat before?" Bingham asks. "No," says Rahn. "Well, this is kind of a pseudo-stat," Bingham says, almost reassuringly. "The baby's heartbeat dropped into the fifties and has stayed down, so we're gonna get that baby out."
Rahn and Bingham — he's at the end of the first year of his residency; she's at the end of her third year — shrug into sterile gowns and take up positions on either side of the mother's belly. Among the 16 people now gathered in the room are three more-senior doctors. With the anesthesiologist, that makes six doctors in all. Bingham looks across her mask at Rahn and takes 15 seconds to plot out what they're going to do. Standing at Rahn's elbow is Dr. Michelle Holt, the senior resident on duty, and she's impatient.
"Go!" she hisses at Rahn. "Fast, fast, fast, Ike! Cut! Cut! Cut!"
Rahn and Bingham make the first cut at 10:44 PM. A pair of pediatric nurse-practitioners are standing by with blue surgical cloths, ready to receive the baby. Rahn works the little boy free at 10:46:30 — just over five minutes from the time the stat was called, just over two minutes from the moment of the first incision, and seven minutes after the previous crisis: Baby Sanchez number two.
"Look at you!" says one of the pediatric nurse-practitioners to the baby boy, who emerges pink and squalling. He's 6 pounds, 12 ounces. "You had us worried." In fact, he's fine.
The Parkland Way
It's hard to find much excellence and inspiration in corporate America in these dispiriting times. Organizations are retrenching, employees are feeling betrayed, and CEOs are being handcuffed and led to jail. Some of the economy's most high-profile figures — giants like Warren Buffet and Alan Greenspan — have gone public with their feelings of disgust about the current state of business. Leadership? Innovation? Passion? Joy? They are all in depressingly short supply.
And then there is Parkland Memorial Hospital. Last year, Parkland delivered 16,597 babies. Not only is that more babies than any other maternity ward in America, it's also more babies born in one Dallas hospital than were born in 10 of America's states, as well as the District of Columbia. It's a whole new 1,000-student elementary school every 22 days. Indeed, it's 4 out of every 1,000 babies born in the United States.
But what's most impressive about all of those babies is how good Parkland is at getting them born safely. On neonatal death rates — how many babies die within the first month — Parkland beats the national average. For African-American babies, Parkland's neonatal death rate is roughly half the national average. Parkland's rate of stillbirths is lower than the national average, its rate of very-low-birth-weight babies is lower than the national average, and its C-section rate is 21%, compared with a national average of 24.4%.
That impressive performance becomes astonishing when you consider the population that Parkland serves: 95% of the women who deliver at the hospital are indigent. Because Parkland is the county hospital in Dallas, its maternity service takes all comers, from private patients to illegal immigrants. One recent day, at 3 AM, the women in labor included an HIV-positive African woman who had never received anti-AIDS drugs, a woman going through alcohol detox, a woman going through heroin detox, a woman preparing to deliver twins, and a 24-year-old woman who had come to deliver her third baby — only to be diagnosed with acute leukemia through routine blood tests. Through it all, Parkland manages to do another impressive thing: It spends less money per baby than the national average.
In short, when it comes to the life-and-death business of delivering newborns, the labor-and-delivery wards at Parkland do more, better and less expensively, than any other maternity ward in America. "We don't have fancy birthing rooms, hardwood floors, and pretty wallpaper," says Reina Duerinckx, an RN. "But we have the important stuff."
Dr. Charles Lockwood is former chairman of the committee on obstetric practice for the American College of Obstetricians and Gynecologists and is the current chairman of the OB/GYN department at Yale's School of Medicine. "Parkland has an excellent reputation," says Lockwood. "It's a little like the Marines down there, like battlefield training. But they do a lot well with very few resources."
And they do it by careful design. You've heard of the HP Way and the Nordstrom Way? There is, most assuredly, a Parkland Way, a strategy for performance, innovation, and customer care that embraces a set of contradictory — even counterintuitive — ideas.
The L&D areas, for instance, operate within rigid, carefully codified rules about medical practice, a method that is unusual even for an academic medical center. But those rules play out in a workplace culture of notable informality and flexibility. Parkland's L&D staff constantly manages to turn adversity into advantage. Practically overwhelmed by the increasing number of babies, critically short of nurses, and operating in a building designed for 3,000 fewer births a year, Parkland's L&D department has had to reengineer how it delivers babies several times over the past 20 years. Some measures adopted in desperate efforts to keep pace may actually have improved patient care.
The professional staff in Parkland's L&D areas is divided into an elaborate hierarchy. At any given moment, there are 14 distinct levels of medical staff, from nurse's aides ("OB techs") to attending physicians with years of experience. The hierarchy involves a precise definition of duties and authority at every level: There are three different kinds of nurses, for instance, each allowed to do different things. And yet in practice, the L&D floors could not be less hierarchical. L&D has an egalitarian, all-hands-on-deck spirit.
Parkland manages to cultivate in its staff a fierce sense of pride in Parkland, Parkland's mission, and the Parkland Way. "I love this place," a dozen different staffers say. But the staff also has a restless dissatisfaction with how things are done now. Not only is there no sense of strutting because Parkland is the biggest and one of the best maternity wards in America, there is also an utter lack of complacency.
"This is not a building," says Dr. Kenneth Leveno, head of the obstetrical service at Parkland and a professor at the affiliated medical school, University of Texas Southwestern Medical Center at Dallas. "It's an idea. It's an organized system with expectations, a team approach. The staff believes in Parkland obstetrics. It believes in taking care of people well."
Power of Rules, Value of Roles
At 7 AM, the area around the nurse's station on Parkland's L&D West is crowded with women and men in blue surgical scrubs. Some are talking to each other; some are doing charts; some are gazing at two vast whiteboards that list every woman on the ward, along with a richly cryptic set of data about each one, from age and number of weeks pregnant to number of previous pregnancies and stage of labor.
L&D West is the heart of Parkland's maternity operation, an H-shaped set of hallways where women with potentially complicated deliveries are taken care of. When the going really gets tough — when a dozen women are laboring in the halls because the rooms are full, when complications come along that a doctor at another hospital would only see once in her career — the wave breaks on L&D West.
It is a universe unto itself. There are no windows; neither the time of day nor the weather intrudes. The place is the same at 3 PM and 3 AM. No TV plays CNN. The only news that matters is listed on two six-foot-wide, handwritten patient-status boards. The only things that vary are the tempo and the energy level.
And at 7 AM each day, clerks, nurses, and doctors all change hands. Everyone needs to brief everyone else. The new charge nurse takes command of the board and a walkie-talkie that links her to the other charge nurses and physicians. New nurses coming on duty stand by for assignments and to learn details about each patient. The senior resident takes command of a half-dozen more-junior doctors.
An outsider watching the transition can't tell the most senior doctor from a nurse who's still in training. (Eventually, it's clear that the busiest doctors are the most junior, and the busiest nurses the most senior.) People call one another by their first — or last — names, without resorting to titles. Everyone wears the same blue scrubs, and doctors and support staff share locker rooms without regard to rank. "It's important that there be roles," says Dr. George Wendel, who has been at Parkland since his own residency in 1978. "It's not so important that there be boundaries."
In fact, there is a careful system behind the success of L&D, one that has been honed over 50 years. Parkland's L&D areas rely on a set of protocols that define every step of the medical experience for women. The protocols — actual rules that are written down and taught — specify which questions a woman should be asked in a satellite clinic during her first prenatal visit. The protocols specify that at Parkland, RNs do not do pelvic exams — those are for doctors, midwives, or nurse-practitioners. The protocols specify that women in high-risk labor not get fluids by mouth — no juice, no popsicles, no ice chips (IV fluids are preferred).
But these are not rules for rules' sake. "The protocols are not recipes," says Miriam Sibley, who has risen through the ranks from L&D nurse to senior VP of Parkland's Women and Children's Services division. "They give us a way to organize a tremendous amount of work."
Says Dr. Steve Bloom, associate medical director of L&D: "Without the protocols, well, you've got 50 faculty members, 40 midwives, and 100 nurses, all practicing medicine. It would be chaos."
The protocols define a standard of practice. They set a floor for the kind of medicine that everyone should get. And although many hospitals have rules and procedures, Parkland's system, which is constantly being refined using clinical research, is much more developed. "People used to say, 'Oh, Parkland is all cookbook medicine,' " says Lockwood of Yale. "Up here in the northeast, we used to say, 'We believe every patient is an individual with her own unique set of variables. There's no way we could practice cookbook medicine.' Well, guess what? We were wrong. The protocols reduce variability, error, and cost, and they increase care. It seems Parkland's is a better way of doing things."
More than that, says Leveno, "the system gives the staff a sense of order, even if you are overwhelmed. Things settle down and function. Otherwise, the volume creates a frazzled environment. The staff gets frazzled, and the patients get frazzled too."
Adversity Into Advantage
Two doctors are sitting by the nurse's station, just outside their lounge. Dr. Lan Tran, about to be a fourth-year resident, asks her colleague, "What's the most deliveries you've done in 12 hours? I've done 13." Dr. Whitney Mascorro, just finishing her first year as a resident, replies, "I've done 14. I've come in with a can of Dr Pepper from home and not had time to drink it."
For a typical OB in private practice, 14 deliveries would be a busy two weeks, not a busy 12 hours. The pace of babies being born at Parkland dominates the culture and psyche of L&D. The staff lives a professional version of dog years, seeing as many patients in a year as the staffs at even busy hospitals see in four or five years.
The protocols are not just a way to manage the waves of work that arrive without warning. They actually provide a structure that gives Parkland L&D room for innovation and flexibility. The protocols offer a kind of liberating safety net.
In the mid-1980s, when births at Parkland first started to rise dramatically, the hospital and the medical staff cast about for a way to take care of all of the women. Because Parkland is both a public hospital and a teaching hospital, new patients almost never arrive with their own doctors, as they would at a private hospital. And Parkland can't simply add doctors to match volume. The size of the medical-school faculty and the residency programs is geared toward teaching, not patient-care demands.
Leveno and the Parkland administration decided to try using certified nurse-midwives — to put them on staff and reorganize not just the medical staff, but also the patient flow and the geography of L&D, around their arrival.
"The conversations weren't just about how to solve the problem," says Miriam Sibley. "They were about how to solve the problem and keep the same level of quality. It's important to be said: We weren't just resolving the crisis of the moment. It was a whole new role. There was certainly some gnashing of teeth."
Midwives were designated to handle routine deliveries. Patients were separated between L&D West and L&D East, between complicated deliveries and routine ones. The midwives preside over East under the supervision of the same doctors who run L&D West.
How has it worked out? Parkland now has 39 midwives on staff, 6 of whom are on duty at all times. It's the largest midwifery program in the country. Midwives deliver 40% of the babies born at Parkland (compared with 7% nationally). The hospital has started a midwife school to guarantee itself a steady supply of staff in years to come.
"We could not survive without the midwives," says Idella Williams, an RN and associate director of all of L&D. "They take a lot of time with the patients." Indeed, there is general agreement that the midwives have the time to deliver better "care" (as opposed to medicine) than the always-harried doctors and nurses.
That strategy — looking at the work to be done, seeing if part of it can be pulled away and done differently without harm — has been so successful that it has become a Parkland hallmark. It is, in fact, the way that the maternity operation turns adversity to its advantage. At Parkland's prenatal clinics — 95% of the women who have babies at Parkland receive prenatal care — women are more often seen by nurse-practitioners than by doctors. In the past year, Parkland has also added OB techs and more licensed vocational nurses (LVNs) to the units. Both are supervised by RNs, and both lift routine duties from a nursing staff that Williams says is chronically short by four RNs per shift and has been for a decade.
The most important result of the intricate layering of staff is that at any given moment, a woman gets what she needs from the right person for that job. If an OB tech can do the task, there's no need to have a nurse do it. If a nurse-practitioner can deliver prenatal care, there's no need to have a doctor do it.
At many workplaces, such fine divisions of job responsibility could easily backfire, with people standing on ceremony about exactly what is and is not their job. You'd think that would be even more true at a place, like Parkland, where people often climb the ranks over the years. Part of the virtue of becoming a Level 9 is that you no longer have to do the work of a Level 5.
In practice, the culture at Parkland is exactly the opposite. No one is too good to do any job. Doctors mop out delivery rooms to make way for the next mother. And while doing that is not in the protocols, it is still very much a part of the Parkland Way.
"When you first come here as an intern, you get a speech," says Dr. Tran. "They tell you, 'You are an intern or resident. You are replaceable. The nurses are not. They are busy. Do what you can to help. Be nice to them. Be smart.'
"I'm not too good to clean rooms, to mop floors, to take vital signs," Tran continues. "And when a new intern watches me clean rooms, she'll say, 'If a fourth-year doc can do it, I can do it.' "
The teamwork becomes instinctive. Says Idella Williams: "When you call a stat C-section here, you think, Boy, I need help, I hope someone comes. And then you get back there to the OR, and the doors open, people have dropped what they were doing, they are pouring in from all corners, they get right into position. And you think, I'm so glad. Then the baby's out, the baby's fine. And the doors open again and everybody's gone. Those are my proudest moments here."
Triumph and Tragedy, One Woman at a Time
The birthing rooms at Parkland do have cable TV — 21 channels — but the TVs themselves are so ancient that everyone on the screen appears to be a ghostly purple. Rooms have no CD players, but when a nurse requests a doctor because a baby's heart rate has dropped, four MDs are in the room in 45 seconds. There is nothing grim or threadbare about Parkland — neither the building nor the attitude. But the experience of being a patient must sometimes seem brisk, if not dizzying.
"When nurses interview for a job," says Williams, "I tell them, You may not get to sit with your patient and spend 30 minutes holding her hand. You have to learn to provide a lot of support in five minutes."
Says Lan Tran: "This place may not be warm and fuzzy, but if you have a problem, it's the place to be."
And yet, another part of the culture is Leveno and Sibley's insistence that "We don't take care of 16,000 women. We take care of one woman at a time."
Miriam Sibley, for instance, has her prenatal clinics mystery-shopped in an effort to make sure that even illegal immigrants are getting the right level of customer service. Parkland runs a van service — the "Mom Mobile" — for pregnant women who don't have their own transportation.
And at a place like Parkland, the staff is self-selecting. "This is not the kind of job you come to just to get a paycheck," says Tammy Rogers, an RN who started at Parkland as a nursing student. "It is so busy. It has to be in your heart."
Idella Williams has a special connection to the place: She was born at the hospital. "I've always known that I wanted to work at Parkland," she says.
When Bridgette Drayden, a new LVN, is asked how she made the decision to work at Parkland, she smiles as if no one has ever asked her that question before. "I was a pregnant 16-year-old, and I came here to have my first baby," she says. "They didn't treat me like I was illiterate or an ignorant girl just because I was black or 16. They treated me like a pregnant woman. I never forget the care they gave me here."
Dr. Michelle Holt, a chief resident, is often in delivery and operating rooms just to supervise the more junior doctors. But in a C-section, she is often the first person to leap to the mother's head, behind the drape, to offer exuberant congratulations, sometimes in Spanish, and to report the sex and weight of the baby.
Amid the heavy, ceaseless crush of work, Parkland L&D even manages to do the most difficult things with grace. On a recent Wednesday, the first delivery after dawn is a routine C-section. A woman is about to give birth to her fourth child. The mother doesn't speak English. Although there are seven people in the room with her — three nurses, a doctor, a nurse-anesthetist, an OR tech, and a translator — OR 5 is unnaturally quiet. The mother has asked her husband to stay out in the waiting room.
The C-section begins just before 8 AM. Reina Duerinckx is training two LVNs, including Drayden. Duerinckx is careful to keep the mom covered. She shows the two junior nurses exactly how to fill out the baby's birth certificate. "Here are the ink pads for the feet, and the camera for pictures. Make sure that you get the baby's toes down on the certificate — they're the cutest part."
An hour after the prep has begun — with the mother's belly scrubbed and the epidural anesthesia in full force — two young surgeons come to scrub and to begin the C-section. Just as they're about to start, Duerinckx calls on the intercom for two more-senior doctors, who observe.
No music plays, and except for the occasional soft request, or bit of advice, the room is quiet. Sixteen minutes after the first cut, Dr. Laura Heinlen says, "Here comes the baby. It's a girl." The two LVNs take the little girl — 7 pounds, 3 ounces — and clean her up carefully and gently. They get her footprints, and they dress her in a tiny, yellow lace gown, complete with matching booties and a yellow knit cap. They take three pictures, then Bridgette Drayden carries the girl to her mom, who is waiting patiently behind the blue drape, while the surgeons do the tubal ligation that she has requested.
The nurse-anesthetist unstraps the mom's arm, and she cradles her daughter, whose mouth is curled into a small frown, to her own cheek. Drayden gives her a sympathetic squeeze, and although no one hurries her, the mother hands the baby back after just a minute or two. A tear rolls down her cheek.
The little girl is dead. She's a full-term, 40-week baby, and just a week earlier, during a routine exam, the baby was alive. On the patient-status board on L&D West, the case had been listed "IUFD" — intrauterine fetal demise. Even at the busiest maternity ward, a full-term stillbirth retains incredible power. It's a permanent sadness for the mother, a palpable failure for one of the safest maternity wards in America. As with everything at Parkland's L&D, the staff has a special way of handling IUFD. The mother will get the certificate with her baby's footprints, the pictures, the yellow lace gown.
It is the first time that Drayden has had such a case. "I wanted to make sure that the mother was as comfortable as possible," she says. "It would be the first and last time she'd see her baby.
"The thing is, whether the patient leaves holding this brand new bouncy baby or she's had a baby die, you want her to feel that the care was there in either case, that she wasn't alone. And for the next delivery, she'll come back, and we'll smile with her."
But Drayden is not smiling. Not now. "I walked around sick all morning," she says. "I had to go get pictures of my kids and look at them."
Charles Fishman (firstname.lastname@example.org) is a Fast Company senior editor and the father of two young children.