182183Reaching for Excellence: Birth Center Standards and Accreditation SUSAN RUTLEDGE STAPLETON AND ROSEMARY SENJEM LEARNING OBJECTIVES Upon completion of this chapter, the reader will be able to: 1. Describe the history of the development of the national Standards for Birth Centers and birth center accreditation 2. Understand the difference between accreditation and regulation 3. Discuss perceived barriers to accreditation and opportunities for wider adoption of birth center accreditation HISTORY OF THE DEVELOPMENT OF BIRTH CENTER STANDARDS AND ACCREDITATION Focus on quality and safety has been a key aspect of the birth center movement from its inception. The foundation for quality and safety is the triad of evidence-based standards, state licensure, and national accreditation. Pioneering experts in maternity care have worked collaboratively for decades to assure this strong foundation for today’s birth centers. This story of foresight and vision describes the process of establishing national birth center standards based on the best available evidence, development of an accreditation mechanism that includes peer review, 184and the impact of these pioneering achievements on contemporary birth centers. In 1975, after 5 years as the director of Maternity Center Association (MCA), nurse-midwife/anthropologist Ruth Watson Lubic opened the first demonstration of a licensed, accredited, freestanding birth center with reimbursement for services from the largest health care insurer at the time, Blue Cross and Blue Shield (BCBS) of Greater New York. Since there were no birth center-specific standards for accreditation, regulations for licensure, or contracts for payment of services in place, MCA worked with existing agencies. This set the precedent for the future development of the essential foundation for birth centers. The MCA’s Childbearing Center (CbC) was given a temporary license under the New York Ambulatory Surgery Center Regulations and was accredited by the combined American Public Health Association (APHA) and National League for Nursing’s Accreditation of Community-Based Health Care. The negotiation of a contract with BCBS included permission to monitor and evaluate the safety, satisfaction, and savings of the demonstration birth center. The payer found that the birth center provided safe care based on evaluation of basic perinatal outcomes; women reported high levels of satisfaction with their care, and the birth center achieved a cost savings of up to 40% over hospital confinement (Canoodt, 1982). This study set a precedent for the rigorous and objective evaluation of the birth center that continues today. Meanwhile, there was vigorous and often contentious debate opposing out-of-hospital birth (Lubic, 1979). Opponents ultimately accepted that women were seeking an alternative to the medical routines of hospital-based maternity care, and there was agreement that development of systems to assure safety and quality care was critical. In 1979, MCA brought together directors of 14 early birth centers to identify their needs and discuss how best to meet them. The major issues identified were the need for national standards, licensure regulations, reimbursement for services, and evaluation of the birth center model of care. In May 1981, MCA received a grant from the John A. Hartford Foundation to convene a group of maternity care experts to explore: • Promoting a wider public understanding of the birth center concept • Supporting the development of a birth center trade association • Developing and publishing national standards • Making recommendations for regulations to guide public health officials, policy planners, and payers 185Standards and regulations for licensure as an ambulatory surgical center were not appropriate; thus, it was critical to develop standards specific to the birth center midwifery model of care. Information collected from existing birth centers was used to define the birth center, and Recommendations for Establishing Standards or Regulations for Freestanding Birth Centers was published in the February 1982 issue of the newsletter of the Cooperative Birth Center Network (CBCN; American Association of Birth Centers [AABC], 1982). CBCN became the trade association for birth centers and is now called the AABC (see Chapter 1). In 1982, the APHA published its Guidelines for Licensing and Regulating Birth Centers (APHA, 1982). These guidelines have served as the basis for birth center regulations across the United States, and continue to be used as the foundation for new state regulations. Table 8.1 summarizes the APHA guidelines. As the debate about safety of out-of-hospital birth intensified, the Institute of Medicine (IOM) appointed a research committee to review all of the scientific literature on all birth settings. The IOM and National Research Council report, Research Issues in the Assessment of Birth Settings (1982), essentially found no reliable evidence about the safety of any birth setting and offered recommendations for conducting future research on all birth settings (IOM and National Research Council (NRC) Committee on Assessing Alternative Birth Settings, 1982). TABLE 8.1 Guideline Areas Addressed Definitions Birth center; low risk and licensed birth attendants Staffing Administration; clinical, staff; volunteers and personnel providing patient and other services; advisory council Facility Design; fire and safety; equipment Services Selection of clients; orientation and education; prenatal care; surgical services; intrapartum care; analgesia and anesthesia; postpartum and newborn care; food service; referral to other community services Policies and procedures Organization; consultation; transfer and transportation; health records; program evaluation; quality assurance; accreditation Source: APHA (1983). 186Exploratory meetings with both the Joint Commission on Accreditation of Hospitals (JCAH), now The Joint Commission (TJC), and the Association for the Accreditation of Ambulatory Health Care (AAAHC) occurred in 1984 and participants determined that accreditation within their organizations was not feasible. Consequently, in December 1984 MCA obtained funding from the Pew Charitable Trusts and brought together representatives of birth centers, consumer organizations, and maternity care professionals from the private and public sectors in Philadelphia to discuss writing national standards for birth centers and establishing a mechanism for accreditation. This meeting was called the Forum on Health Policy Issues of the Freestanding Birth Center and the trade association published essays by some participants in its newsletter. The issues were identified, with a particular focus on safety, and debated before arriving at the general consensus that the standards should reflect midwifery care, and be flexible enough to allow continued development of an evidence-based model of care to be evaluated by an accreditation process. AABC board member Charles Mahan, MD, FACOG, volunteered to chair the trade association’s new standards committee; Eunice Cole, RN, immediate past president of the American Nurses Association, volunteered to chair the new Commission for the Accreditation of Birth Centers (CABC), which was yet to be formed under the AABC; and birth center midwives and administrators volunteered to train and serve as CABC site visitors (Ernst, 2015). In March 1985, AABC published the first national Standards for Birth Centers after the standards were unanimously adopted by the trade association members. Here is an excerpt from the introduction section of this landmark document: Quality assurance is an evaluation function that is both external and internal to the birth center. Licensure and accreditation constitute two arms of external quality assurance. Licensing agencies are officially charged by the federal, state or local governments to protect the public and monitor safety through codes, ordinances and a variety of regulations. This first level of external quality control requires that the birth center meet defined criteria for licensure in order to operate as a business or health care facility. But the level of quality required for licensure may vary from one locality to another. Some states and municipalities are non-specific or uneven in their requirements 187for regulations while other states may be very specific and uniform in the level of requirements for safe operation. A second level of external quality assurance is a national program of accreditation. Standards and attributes for accreditation are uniformly applied in all localities, thereby eliminating state and local inconsistency. It is a voluntary program that places the level of quality desired above that which the state may require. Internal quality assurance begins at the earliest stages of planning of the birth center and comprises a systems approach to evaluation of operation and services. Like all new health care facilities, the birth center has the opportunity to build evaluation mechanisms into all facets of the organization and operation. If attention is given to establishing a strong program of quality assurance in planning the freestanding birth center, application for licensure and accreditation are simply a form of external review—an opportunity to be evaluated or measured by established yardsticks for required and desired levels of excellence. (Standards for Birth Centers, American Association of Birth Centers. [1985–2013]. Reprinted with permission.) This achievement was the result of the culmination of nationwide efforts by birth center founders and stakeholders since 1975, including the demonstration CbC by MCA of New York. MCA’s demonstration project included (Ernst, 2015): • Identification of criteria for low-risk pregnancy and birth • Development of policies and procedures for operation of a birth center as a place for the midwifery model of care, and connected to the existing system of health care • Design of record forms including an extensive informed consent • A health record that reflects the care provided and the instruction of clients on health relating to pregnancy, birth, and early parenting • Evaluation mechanisms for all aspects of the program offered At this same first annual meeting of the trade association, their board voted to “establish a separate association to be called tentatively, the Association for Accreditation of Birth Centers.” This would become the 188CABC and was ultimately founded under the trade association to (Ernst, 2015): • Evaluate the quality of birth center services • Promote the development of national guidelines for licensure • Review state regulations for birth centers • Explore and evaluate the programs of other accrediting agencies • Support the expensive process of accreditation with resources from the trade association In the fall 1985 newsletter, the trade association announced that “Additional funds have been secured to continue the Pilot Program on Accreditation of Freestanding Birth Centers” (AABC, 1985b). MCA funded this program to develop and conduct an accreditation process for 12 birth centers, which led to the establishment of the CABC. Then, a landmark meeting was held in Philadelphia of the newly formed CABC and newly recruited advisory council to the CABC to evaluate the work of establishing the national standards and applying them in the pilot program for accreditation. The advisory council to CABC, led by H. Robert Cathcart, who was president of Pennsylvania Hospital and a commissioner for JCAH, included representatives from a broad group of stakeholders and experts, including midwifery, obstetrics, neonatology, nursing, public health, birth center parents, birth centers, vice president of the Health Insurance Association of America (HIAA), vice president of Pennsylvania Hospital in charge of hospital accreditation, and federal policy maker. After one and a half days of deliberation, the consensus for how best to reach for excellence through National Standards and Accreditation for Freestanding Birth Centers was that “in this time of rapid change, the CABC had the best prospects of developing a high quality program of accreditation for birth centers and should continue to pursue it, cooperating with other agencies as the opportunities arise” (Ernst, 2015). The following are excerpts from papers presented by advisory council members and later published in the trade association’s newsletter: • “The Health Insurance Association of America (HIAA) supports the development of quality care review programs by member companies as well as by other entities within the private and public sectors. . . . 189HIAA recognizes that birth centers address the desires and demands of many childbearing families. However, the birth center holds the same potential for being abused or corrupted as nursing homes, hospices or any other care facility that may emerge outside of established mechanisms for measuring the quality of care provided. The established mechanisms are state licensure and national accreditation.”—Stanley B. Peck, MBA, vice president, HIAA (Peck, 1987) • “Quality assurance mechanisms must be expanded into non-traditional settings. . . . It is important for birth centers to give attention to accreditation if they want to retain responsibility for development of the birth center concept.”—Eunice Cole, chair, Commission for Accreditation of Freestanding Birth Centers (Cole, 1987) • “The importance of accreditation to ‘emerging’ organizations like freestanding birthing centers is critical. Accreditation of birth centers like the accreditation of hospitals will become a franchise to do business. Loss of accreditation for hospitals in Philadelphia means loss of reimbursement. Accreditation for birth centers will, in all probability, also become a preclusion of entry into ‘the market’ for those who cannot meet select standards. It provides a legitimacy and will be valued in the face of skepticism from childbearing women or from physicians who have been trained to view the hospital labor floor as the only safe and responsible location for childbirth. Hospitals that dare to associate with such iconoclasm as the birthing center will dare more readily if a center is ‘accredited’ by a reputable body. . . . Hospitals will be eager to see that birthing centers have in place systematic and comprehensive Quality Assurance mechanisms that parallel the licensure, accreditation, quality assurance and insurance data systems that affect hospitals. There must be assurance that birthing centers have been deliberate in their self-evaluation, that they will not admit or hold women unwisely and that providers’ practice patterns are reviewed periodically. These practices, in my opinion, will contribute significantly to acceptance and trust of birthing centers by hospitals providing back-up services to birth centers.”—Bruce Herdmon, PhD, vice president, Pennsylvania Hospital, responsible for hospital accreditation (Herdmon, 1987) The first CABC board of commissioners, led by Eunice Cole, also included nurse-midwives, obstetricians, a pediatrician, and a representative of the public. The advisory council to CABC remained in place 190through 1988. CABC accreditation was designed as a peer review process and birth center midwives and administrators volunteered to train and serve as CABC site visitors and continued to do so up to the end of September 2014, when CABC hired staff to fulfill this role. CABC separated from AABC in 2002 as planned from its founding, and incorporated as a separate not-for-profit entity. CABC continued to conduct accreditation activities with a volunteer corps of commissioners and site visitors until October 2014. With the support of accredited birth centers, CABC was able to raise its fees substantially and adopted a different business model with all staff site visitors to meet the demands of growth. In March 2015, CABC added a board of governors to allow for fund raising to retool for growth and further develop the organization’s outreach. In September 2015, CABC published its first reference edition of the Indicators of Compliance With the Standards for Birth Centers, which revealed CABC requirements for accreditation, listed unacceptable practices, and included a glossary of terms, linked index, and reference citations. In January 2016, after more than 30 years, CABC reached the milestone of 100 currently accredited birth centers. ACCREDITATION: WHAT IS IT? WHY DOES IT MATTER? Accreditation is a nongovernmental process in which certification of competency, authority, or credibility is presented. A wide and growing array of fields use accreditation, including health care, veterinary medicine, engineering and manufacturing, education, language translation and interpretation, and public relations. It is common for standards and accreditation to originate in a trade association or professional organization, for example, TJC was created jointly by the American College of Surgeons, American College of Physicians, American Hospital Association, and American Medical Assoc i ation (TJC, 2016). When the accreditor’s scope is confined to the review of a small or finite number of organizations, the accreditor typically remains under the originating organization for support. For example, Accreditation Commission for Midwifery Education (ACME) is a commission of the American College of Nurse-Midwives (ACNM), which provides some funding for this function (ACNM, n.d.). When an accrediting organization has enough volume to spread out the costs, it can achieve financial independence as seen with larger accrediting organizations, such as TJC and the Commission on Collegiate Nursing Education (CCNE). 191The purposes of birth center accreditation are to: • Hold the accredited birth centers accountable to the community of interest—childbearing families, collaborative health care professionals, payers, other birth centers • Assess the extent to which a birth center meets national accreditation standards • Inform the public of the purposes and values of accreditation and identify birth centers that meet accreditation standards • Foster continuing improvement in birth centers—and, thus, in professional practice and maternity care in general
American Public Health Association Guidelines for Licensing and Regulating Birth Centers (APHA, 1983)
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