Miracle of Birth

"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."