Miracle of Birth

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.