How does your state handle client complaints?

[mothercat]

Because of a series of threads that have popped up here recently I have gone back and read some of the threads dealing with providers (midwives and physicians) who have treated women poorly during pregnancy or labor. Obviously, with licensed providers you can file formal complaints with their licensing board. With CPM's you can also go to NARM.

However, in states where CPM's are not licensed, how do the state midwifery organizations handle client complaints?

I would like links to web sites describing the grievance process. I used to have a link to the Idaho midwives and their information was excellent. but now it seems to be non-operational.

Thanks so much for taking the time to respond!

[mwherbs]

peer review--

although in an illegal state harder to pull off- and even in legal states providers have sued or threatened suit for actions against them...
my long time preference is education- improving care has more to do with education than anything else--

[mothercat]

Education is always a good place to start and I think it is part of NARM's grievance process. If a midwife has had complaints filed against her and peer review finds she may be lacking in critical areas, she is asked to work on this and to work with a more experienced midwife to fix these issues.

However, what if the midwife does not agree with the peer review findings and begins to dissociate herself from the larger midwifery community under the guise of "They just don't understand how I practice."

[courtenay_e]

Or, what if she simply decides to not participate in peer review?...

[mwherbs]

-----------MAKE MIDWIFERY LEGAL-----------

simplest answer- doesn't get rid of the bad providers as much as it makes a way for consumers to have a degree of recourse and if a provider cares about license status- a reason to comply with remediation that is put foreward-- and another thing that legalization would do is offer a degree of variety - easier to find a mw- stuff like that it takes years and years of legality for midwifery consumers to increase so there would not really be a big explosion of new midwifery clients nor in midwife numbers but being legal is the first step--

as for education, there are all sorts of ways to educate- not just midwives but consumers as well-- small classes, conferences, demos , articles, the web---
I think that consumer feedback can be an important source of change for some midwives- now I am not too sure how effective furious people will be but you should write or communicate your experience as best you can so that the midwife knows about your feelings, I think that if you have mixed feelings some good some bad that type of communication ends up being taken in more readily
sometimes it is a student that can help a midwife to learn.

Is there a way to have common ground and have some mutual respect ? what if you were doing outreach in a 3rd world country, how would you approach to train - there are books like - Where There is No Doctor and Teaching Midwives- now not so much the medical details in those books but the approach to working with people who are already providers in their own right and are respected and trusted in the communities they live in. we aren't shooting for clones of us what we want is competence and diversity. what is appropriate technology for this person?

[michiganmidwife]

Also, even in the case where a CPM has had credentials revoked, complaints can still be made on that midwife to NARM. The midwife will have to deal with the complaints prior to reinstating certification if and when she is eligible for that.
I suppose that the next best way is to call for peer review. Although the midwife might decline, it would at least bring to her attention that there is a problem.

[mothercat]

Thanks mwherbs for the replies and the PM. This information is going to be much harder to come by than I thought. I did find the Idaho stuff I was looking for. I had it bookmarked.
I had been asked to look into this and collect some info about how other state midwifery organizations in unlicensed states have handled this. Some groups feel that they need to give consumers a place to bring their complaints so they feel as though someone is listening, and other MW organizations feel their mission is to support the midwives and offer educational programs and networking opportunities.
I suppose midwives are unique in this way. I can't see a group of physicians providing a mediation session for patient complaints. More hospitals and physician groups are requiring binding arbitration agreements.

I think my best bet will just be to check each state midwifery organization website. It will be a lot of work because the CPM's and CNM's usually have separate web sites.

Might just as well consider this thread closed. Gee, don't hear a little Kentucky and Oklahoma in there, do you?

[mwherbs]

similar issues even in licensed states because-- look at Washington- they have no self -governing or say so -- someone in a completely different field and with different training decides what they think a midwife should be doing- the investigators have bankrupted the midwifery licensing -- and have been basically writing themselves a blank-check to spend prosicuting midwives-- even when there are no client complaints!!!
Years ago Texas had midwifery registration- so as a midwife you registered with the health dept-- and clients could leave feedback- good or bad about you- probably the low tec equivalent to the ebay feedback system--
if you get the process in place before you get licensing then maybe your system can just -Plug in

[mothercat]

Well, I went to the CFM site and started poking around in the various state sites. There is darn little to be found when it comes to clients' grievances.

Thank you for the advice about having a grievance/discipline process in place first. That makes sense that if there is already a process in place, then the state would feel less inclined to set up a system of their own. And the midwives avoid the possibility of dealing with an inappropriate bureaucrat who is already too busy.

In your original PM, you mentioned that MI has an active midwifery community. I used to be on the board for several years. Although peer review is part of what they do, they do not have any sort of policing power. They have made it clear that they have no ability to censure or discipline any midwife.

This appears to be the case with many states where midwives are not licensed.

[bryonyvaughn]

Originally Posted by mothercat

...In your original PM, you mentioned that MI has an active midwifery community. I used to be on the board for several years. Although peer review is part of what they do, they do not have any sort of policing power. They have made it clear that they have no ability to censure or discipline any midwife...

I talked to a current MMA board member and was given the impression if a client requested a peer review the MW could decline it w/o any repercussions *but* if a client files a grievance with them on a CM, and the grievance committee refers it for peer review, and *then* the MW declines peer review, sanctions could be taken against her CM credentials. Did I get the wrong impression? FWIW I realize there are very few MI MWs who retained their CM credentials rather than pursuing CPM credentialing.

~BV

[mwherbs]

CFM has recommendations for filing a complaint to/about OBs .... write and ask about midwifery--- they may have some recommendations.

[mothercat]

Originally Posted by bryonyvaughn

I talked to a current MMA board member and was given the impression if a client requested a peer review the MW could decline it w/o any repercussions *but* if a client files a grievance with them on a CM, and the grievance committee refers it for peer review, and *then* the MW declines peer review, sanctions could be taken against her CM credentials. Did I get the wrong impression? FWIW I realize there are very few MI MWs who retained their CM credentials rather than pursuing CPM credentialing.

~BV

Oh gosh. I think you're right about that. It's because CM's are certified by MMA. What I should have said is, that other than MMA CM's, they have no policing power. I think there are only 5-6 CM's left, and MMA will continue to renew their credentials as long as they meet requirements. As I posted in another thread (O,M,I) that most have chosen to take the NARM exam and there are a few midwives who chose not to do either CM or CPM.

Now just to really confuse things, ACNM also has CM's, but they take the ACNM exam. They are nurse-midwives, w/o the nurse.

Can you imagine how confusing this all is to the consumer. I have talked with a couple of lawyers and we discussed the differences between these groups. They were having trouble following all this w/o a playbook. It would be so nice to be able to say midwife and have the consumer know we all have the same competencies and practice standards, and that they would have just one site to go to for information.

[MsBlack]

Here in IL there is similar lack of licensing and lack of any review process for mws. It is all completely voluntary, whether or not a mw wants to do peer review, or even a one-to-one conversation with any mw or consumer who might want to critique or at least ask some questions. We do have a midwifery consumer support group, who will take complaints from consumers as well as helping to connect consumers to mws and working on licensing legislation.

Having recently spoken to the pres. of this organization, I discovered that while they will take complaints from consumers about a mw, they have no procedure for notifying the mw about this--'not part of our mission'. Which is fairly understandable--there are only so many hours in a day, and the key people of this org are busy busy moms, often homeschooling moms who have taken on work toward midwifery licensing/availability strictly as volunteers. In any event, their operating rule is to simply stop connecting any consumer with a mw who has been the subject of too many complaints; they will also privately communicate about a particular mw to any consumer who specifically asks them about her. But this consists of 'based on the number of complaints we've heard, we do not rec. that mw'.

While I am not a big fan of licensing for any profession, I do see how this lack of accountability and feedback/review process is a very bad thing! Also, we lack even a mechanism for seeing to it that mws get some yearly (or so) cont ed--so a mw trained, say, 10 or more yrs ago might be that far out of date in her knowledge and protocols. If she is basically a loner, in that time she might also have thought up some 'brilliant ideas' of her own, about handling certain things--in a total absence of research or any sort of sounding board or review...needless to say, these brilliant ideas might NOT be so great in reality, no matter how clever the rationalization.

I end up telling consumers who contact me that while I think it's best if they search all available mws before choosing one (and I provide contact info if needed for the others), that it is very important that they not take anything for granted, but ask lots of questions and see if they can obtain professional and client refs on any mw. Any mw will have her fans--but one that can also provide refs from anther mw, a doc/cnm, chiro--SOMEONE who has seen her work from a prof. perspective, has met a few of her clients--well this is a mw who might best be trusted. I try to help them understand that without legal mechanisms in place to assure standards, cont. ed, review, that they have to take it on themselves to explore. Of course, then I let it be--no saying what consumers will actually do for themselves on this.

[mothercat]

Originally Posted by MsBlack

Also, we lack even a mechanism for seeing to it that mws get some yearly (or so) cont ed--so a mw trained, say, 10 or more yrs ago might be that far out of date in her knowledge and protocols.

This brings up another subject, that of staying up to date. I had been hearing about newer, earlier, and more accurate prenatal testing for CF, Down's etc. Well this week one of my families had an US for normal anatomy because they have a family history of congenital heart disease. Well, the heart's OK, but baby has one kidney which can be associated with other syndromes. In the process of checking out the kidney problem a echogenic bowel was found. While this may be a normal variation, I felt way behind the times that I couldn't explain the connection right away. The bowel thing is fairly common and mostly insignificant, but can be assoc. with CF and Down's.
So questions were asked about whether I had early screen results (PAPP-A/early HCG/nuchal translucency) and realized I need to catch up quickly. These test are quickly becoming standard and even if most families will choose not to do them, they should make an informed choice.

[mothercat]

MsBlack
Do the consumers know that their complaints go nowhere, that no action is taken?

[courtenay_e]

Originally Posted by mothercat

It would be so nice to be able to say midwife and have the consumer know we all have the same competencies and practice standards, and that they would have just one site to go to for information.

While this is very true, I don't know that it's at all realistic. For instance, I attended a birth last summer where, by proxy, my client's baby was caught by the head of perinatology. I was absolutely horrified by the violence of the birth, yet all the docs in the room (because of the last minute nature of the birthing--she's a quiet pusher--the nurse had just yelled into the hallway and in came a dozen docs) were clapping the man on the back and giving him atta boys. I asked about the celebration. One of the residents mentioned that, as he's a perinatologist, he doesn't get many catches for vaginal births...at which time he spoke up and gleefully announced that this was his SIXTH career catch. You'd think that, being not only an OB, but the HEAD of perinatology, he'd have had a little experience with birth. But no, he really only has ever done cesareans.

Yes, this is with docs, but just because you are able to pass the test and have somebody sign off on skills doesn't mean that you HAVE the same skills as another person who took the same test.

It doesn't mean you have the same protocols just because you answered the essay questions "correctly"...and even if there IS continuing ed, it doesn't mean they'll take what they learn back to their practice with them.

I was a teacher in my past life (pre kids) and I know PLENTY of english teachers who can't diagram a sentence--heck, I know plenty of teachers who can't tell you when to use "whom" vs when to use "who" let alone teach it to their English students. And we all took the same test.

SO, I don't mean to be the dissenter, as I know that consistency is really a good thing, as I also know that having some kind of repercussions for poor outcomes is a good thing--I've been on the receiving end of a poor outcome, with no available repercussions for the midwife! I just don't think even for a minute that having every midwife have the same initials after their name will solve the problem of differences in practice and protocols. And...frankly, I appreciate the thought that two of my very different friends are able to find two very different kinds of midwives to meet their very different emotional and physical needs in labor. Were we "policed" more strongly, would they have that ability? I'm not so sure. I don't think that, were we living in Florida, they'd have that ability. The midwives there have to follow too stringent and all encompassing guidelines in order to practice at all, and many (notice I didn't say all) women lack the kind of care they'd benefit most from because of it.

THinking out loud, but that's where I am right now...

[michiganmidwife]

Lack of skill, competence and judgment of a provider becomes evident based on a providers good or bad outcomes and level of client satisfaction over all.
Of course, if a provider has a small practice and attends a minute # of births each year (15-20), and they have not been practicing for many years, it may take a very long time for that lack of competence to be recognized.

Also, I think we should give people more credit for being able to have the ability to discern who would be a good provider for them. I don't like the "save them from themselves" mentality. Its arragont.

Bad providers weed themselves out. If a provider has generally happy clients with good experiences overall, his/her practice will flourish.
If the provider has bad outcomes or many unhappy clients with complaints, no one will refer or go to him/her.

[mwherbs]

i disagree bad providers/bad practices continue on , now there may be some alternatives that come up-- but it takes a while--
where I live there are many areas that are under or not served by midwives and the clandestine midwife will crop up on-going teaching could really help these gals out if they would show up, some sort of chart review and skills classes would help -- one in particular I can think of uses Polly's book- even for resuscitation!( its that old fold the baby resuscitation) people to a greater extent are accommodating-- how do you think that the medical system is getting away with so many c-sections if people were so savvy and able to clearly protect themselves- 1/3 of the birthing population would not be having lifethreatening surgeries --- so nope I am not buying it
but to say something I have seen change-- a very very experienced midwife in group practice- who has been to maybe 8000 births and cared for even more women than that prenatally-- until recently did episiotmies - fairly quickly--- she has only recently changed that practice so she is willing to watch a tear happen--- now there is no doubt she is an experienced midwife- but ingrained practice of a type still needed to be changed- and the people who went to her well they may not have complained and they may not have liked the epis

[Defenestrator]

Originally Posted by mothercat

This brings up another subject, that of staying up to date. I had been hearing about newer, earlier, and more accurate prenatal testing for CF, Down's etc. Well this week one of my families had an US for normal anatomy because they have a family history of congenital heart disease. Well, the heart's OK, but baby has one kidney which can be associated with other syndromes. In the process of checking out the kidney problem a echogenic bowel was found. While this may be a normal variation, I felt way behind the times that I couldn't explain the connection right away. The bowel thing is fairly common and mostly insignificant, but can be assoc. with CF and Down's.
So questions were asked about whether I had early screen results (PAPP-A/early HCG/nuchal translucency) and realized I need to catch up quickly. These test are quickly becoming standard and even if most families will choose not to do them, they should make an informed choice.

Are you suggesting that midwives be asked to get CEUs on specific, pre-chosen topics? I don't know of any healthcare profession that asks that of its members. I have always heard of general requirements for a certain number of hours before recertification/re-licensing, to be chosen according to the needs/interests of the healthcare professional.

I also think there is no shame in saying, "Use of diagnostic ultrasound is not common in my practice. Here are my initial comments on your test results. I would also like to take a little extra time and research some of these findings and what they might mean for you and your baby so that we can make sure that there isn't something that might need our attention or planning. I will call you tomorrow with what I have found."

If it makes you feel better, first trimester screening (the combo of the bloodwork and the nuchal translucency) is not common everywhere. In my area none of the practices associated with Catholic hospitals offer it, which means that there are probably 5,000 families in my county and the next county over who are not being offered this screening nor being told that it exists. The testing itself was brought to my attention three years ago when one of my clients was interested in it because of (her perceived) advanced maternal age. I hadn't heard of it before but was able to catch up quickly.

[Defenestrator]

I've been thinking about this topic a lot -- it is interesting to me.

I think that, as a midwife, in order for me to want to expose myself to some kind of organized critical process, there has to be something in it for me. In a legal state, a license is something that (hopefully) offers some benefit to the midwife in terms of legal protection, definition of acceptible practice, and marketing/conferrence of legitimacy. But what does subjecting myself to an organized critical process offer me in an illegal state? Unless there is some kind of filtering/verification/review/answering process when complaints come into an organization, they are relatively meaningless. I am sure every midwife has encountered someone that is just not happy, even though they have received excellent service by most measurable standards. They also would artificially penalize busy midwives. If I attend 15 births a year and have three complaints, I probably am not doing something right, but what about the midwife who attends 100?

If there is some kind of filtering/verification/review/answering process, then the midwife is held to standards which must be determined by a board of (hopefully) peers. Again, if I am not receiving some benefit, like a license, why would I want to conform to someone else's ideas of how I should practice? And what if the complaints don't address issues of safety or protocol, but merely bad customer service? Does that mean that the complaint isn't valid?