Texas Perinatal Services maternal surveyors are 100 percent Texas-based, Texas-experienced maternal health clinicians. In our ongoing Meet the Surveyor series, we introduce you to surveyor Nathan Drever, M.D.
March marks one year since the state’s new maternal verification rules came into effect. What has been the greatest impact of the rules in your perspective, in this first year?
One of the things that has been beneficial for me as a maternal medical director in labor and delivery is the new rules have allowed me and my hospitals to highlight the mechanisms in place that meet the rule. It’s easier to get buy-in from providers across a big system when things are categorized or listed or documented by the state. So it has been helpful for the state to come out with those rules and some instructions on how to meet those metrics.
As a surveyor, I think what’s had the most impact is knowing that other labor and delivery units are all trying to organize themselves the same way that you are. It’s good to see how they are brainstorming as a group to tackle things that sometimes are hard to implement, and also to see different perspectives on how to design your own labor and delivery unit. But because every place is so different, that scaffolding may not be the same from place to place, but you have a blueprint on how to build it. We are all working toward the same goal.
Why did you choose to become a surveyor?
My favorite place to be is in labor and delivery. I wanted to become a surveyor because I wanted to know how to do a top-down assessment of a labor and delivery unit. I wanted to understand what the state of Texas views as important to have to make us a safe site. I wanted to see how other units are getting their work done, and that’s helpful to me in my labor and delivery here locally.
And why with TETAF/Texas Perinatal Services?
I was involved with the NICU survey when it was done here and I went to the morning session where the TETAF surveyors interacted with all the team. I liked the way TETAF’s surveyors interacted with the staff, and how they talked about the potential deficiencies and how to remedy those deficiencies. I liked how they conducted themselves, and their philosophy of surveying with a goal of helping the hospital improve on what it is doing.
How would you describe your role as a surveyor – what is your focus, and what is a typical day like while onsite conducting a survey?
I consider myself the eyes of the state of Texas. I’m observing how things are done and I am reporting back to the state.
When we show up, everyone is usually pretty tense and a little anxious about the process so we try not to contribute to the anxiety. I really think in terms of this: “I want to show you off, I want to find things you guys do well that I can brag about on you, and I want to see if there are any things that could be improved.”
A typical day one starts around 1 p.m. and we chart review until 6 or 7 that evening and sometimes later. That is the most time-consuming part, going through medical records and finding what you need to complete your survey sheet. Then the next day, we get there at 8 a.m. and talk in an open meeting for about two hours with a lot of individuals. We then spend about two hours doing a walkthrough of areas that we think would be informative. We close by giving give them our report. We always start off potential deficiencies, and steps you can take to remedy them. And we wrap up with the things the hospital is doing very well.
Are you seeing some common areas of potential deficiencies?
Common areas of potential deficiencies, and the easiest to address, are guidelines to maternal morbidity and mortality – hypertensions, shoulder dystocia, behavioral health, and so on. Some hospitals have some of those guidelines but not all, but you also have to follow internal policies. They might have guidelines in place for certain things, but don’t have it fully defined, or they aren’t following the guidelines.
The other thing that we all struggle with is the quality process and how to do outreach. Most labor and delivery units do identify problems and how to fix them, but we aren’t always good at tracking to make sure the steps we took worked. A lot of labor and delivery units are holding group quality meetings to assess problems and improvement plans all the time, but if you aren’t taking attendance and minutes and showing that you are implementing changes, it doesn’t look like that. It is important to document what you already are doing. That feedback loop is important before the maternal level designation.
What advice do you have for hospitals preparing for their first survey?
From a logistical standpoint, it is helpful to have a really good electronic medical record system that is fully integrated, but that’s something you either have or you don’t. One facility we surveyed had five different systems to navigate just to get the charts.
Keep in mind that the steps we are taking that we think are going to make us safer are slow, deliberate steps. You have to give yourself enough space and time to get everyone on board and have feedback and understand how the process works. If you can do it slowly and deliberately, you can gradually work these safety features in, and then move to the next one. What sometimes happens is a hospital tries to do everything that the state says we have to do two or three months before the survey. But the survey team goes back a year and is surveying charts before any of those things are in place. The concern is that if you rush to all these changes it might not be something that becomes part of the culture that embraces those changes.
About Nathan Drever
Nathan Drever, M.D., is board-certified in both Ob/Gyn and Maternal Fetal Medicine and has been providing maternal health care in Texas since 2009. He currently serves as medical director of labor and delivery at Scott and White Medical Center in Temple. He trained in two county hospital systems that managed high-risk OB patients and were both referral centers for severe maternal disease and preterm infants.