The greater Milwaukee area provides a wide array of health care services through its many hospitals, clinics, and pharmacies. Services range from primary preventative care to specialists and emergency level care. Aurora Health Care is one of Wisconsin’s largest health care provider systems. Aurora West Allis Medical Center is a non-profit urban hospital located in West Allis, Wisconsin. Aurora West Allis joined the greater Aurora Health Care system in 1995, which now encompasses 13 hospitals and over 140 clinics, and has since become an integral piece of the network. In being a non-profit organization, the hospital is eligible to receive government grants and philanthropic donations but is unable to accept private investments or trade stock shares.
A mission statement should be succinct and convey the essence of an organization’s purpose and direction. It should address the organization’s primary stakeholders, be socially relevant, contain measurable criteria, and serve as a guide to decision making. As stated on the Aurora Health Care website, the mission of Aurora is to:
Promote health, prevent illness and provide state-of-the-art diagnosis and treatment, whenever and wherever we can best meet people’s individual and family needs. We are committed to improving the quality of health care and health outcomes through the rapid and broad application of knowledge. We are also engaged in the education of health care professionals and the ongoing quest for new knowledge through medical research to contribute to the quality of health care in the future. Because we recognize the personal nature of health care services, we are committed to creating environments the meet the diverse physical, emotional, spiritual, social and economic needs of our patients and clients, as well as the people who serve them. We are concerned with the overall welfare of our communities, and we recognize that there are limits to the resources people can invest in health care. Working together, the people of Aurora are determined not only to provide services of the highest quality, but also to make those services affordable and accessible to every person in every community we serve (Aurora Health Care).
The espoused theory of the mission embodies the core importance of health and serving the needs of the patient and community above all. Aurora West Allis values patient relationships, quality, improvement, innovation, efficiency, convenience, employee involvement, satisfaction, and profitability (Aurora Health Care). However, while there are some specifics in the mission in regards to community access, research, education, and realistic cost ideals, there are a few vague immeasurable terms, including quality. While quality is often sought after, it is hard to define; what differentiates quality health care from sub-quality health care? Using comforting, yet superficial, values does not distinguish one institution from another.
In putting their mission and value theories into action, Aurora facilities work together in striving for better access to care and patient outcomes. In Aurora’s commitment to community outreach, the 2009 Annual Report revealed that the community benefits program spent $32,363,109 on education, transportation for patients, counselling, support groups, free clinics, health screenings, and immunizations. In addition, the Aurora Health Care system provided $25,066,000 in charity care to those who were uninsured or unable to pay for their medical services (Aurora Health Care). These expenditures on behalf of Aurora demonstrate the commitment to the mission to “recognize that there are limits to the resources people can invest in health care” (Aurora Health Care). Aurora currently accepts 33 different public and private insurance provider plans, including Medicare, Medicaid (Title 19), and all Medicare Advantage Private Fee for Service plans. The Helping Hand Patient Financial Assistance Program helps patients access and utilize government and/or Aurora programs for payment assistance. In recognition for outstanding care and community dedication, in 2009 Aurora West Allis was also awarded the City of West Allis Community Partnership Award and was ranked as one of the top hospitals by Thomson Reuters 100 Top Hospitals (Aurora Health Care). These financial and philanthropic achievements help demonstrate that Aurora West Allis Medical Center not only strives to provide better patient and community care, but follows through with its missions and is publically honored for its achievements.
In 2009, the Aurora system employed 29,642 people, including 6,021 registered nurses, 3,067 physician on staff, and 146 residents and fellows (Aurora Health Care). Aurora West Allis can be visualized within the Aurora Health Care system using the following Mintzberg’s diagram:
IT, Systems Analyst, Auditors, Business, Finance, Strategic Planning, Operations, Legal
PR, Payroll, Maintenance, Custodial, Food Service, Clerical, Legal
Chief Medical Officer
Chief Nursing Officer
Students Interns Residents Fellows
An advantage to Aurora West Allis Medical Center is its being a part of the Aurora Health Care system. Being a part of, and taking stake in, a larger system is beneficial in that there is a higher level of collaboration in finances, policy making, and health research. Higher levels of funding can be achieved through the variety of locations and health care services provided to Wisconsin residents. Specialization of specific hospital and clinic locations allows for more individualized care tailored to specific patient needs, while the connections to the greater Aurora Health Care system allows for greater continuity of care and allocation of resources. On the other hand, constraints to a larger system include increased bureaucracy, restriction of policy development, and financing. In being a one of many managed sectors of a larger system, more intermediate levels exist between upper management and the functional bottom line of the individual institution. Lengthened chain of command can be time consuming and impede communication and the distribution of services.
One of the highlights of Aurora West Allis Medical Center is the women’s pavilion. The vision for the women’s pavilion embraces the holistic care of mind, body, and spirit. Their commitment as a partner in care is centered in education, individualism, commitment, evidence-based care, integrity, support, cultural sensitivity and inclusion, and coordination across disciplines. The birthing center staff includes, but is not limited to, OB/GYNs, pediatricians, maternal fetal medicine specialists, neonatologists, certified nurse midwives, and registered nurses (Aurora Health Care).
An advanced practice nursing role that is gaining public popularity once again is the certified nurse midwife (CNM). A CNM is an advanced practice nurse that holds either a master’s or doctoral level degree and is educated in both the disciplines of nursing and midwifery. A certified midwife (CM) holds an education in only midwifery; however, both CNMs and CMs are certified by the American College of Nurse Midwives (ACNM). While current regulations allow CNMs to practice with only a master’s degree, in 2015 the requirements for obtaining an advanced practice level degree will become the doctor of nursing practice (DNP) (Krejci & Malin, 2010, p. 78). The United States Department of Education recognizes the ACNM as the accrediting agency for midwifery and the ACNM Certification Council, Inc. administers the certification exam (Summers & Williams, 2003, p. 30). CNMs that were licensed prior to January 1996 have midwifery licences that did not carry an expiration date and were therefore were considered valid for life. As of 2010, new regulations require that any midwife, regardless of certification time, must renew every five years (American Midwifery Certification Board, 2005).
CNMs legally practice in all 50 states and work in collaboration with registered nurses, OB/GYNs, physician specialists, and other advanced practice nurses. Since CNMs typically care for healthy women and do not participate in high-risk pregnancies or invasive medical procedures surrounding perinatal care and birth, the collaboration with physicians is crucial. The majority of CNMs practice in partnership and under guidance of a physician; however, individual state laws determine whether CNMs fall under the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) definition of a licensed independent practitioner (LIP). An LIP is able to practice within the scope of their license without supervision or direction of another provider’s license. As of 2003, CNMs and CMs were classified as LIPs in nine states. As with other APNs, with proper licensure and a Drug Enforcement Agency (DEA) number, CNMs are able to prescribe medications. The role of the CNM, as defined by the ACNM, is the “independent management of women’s health care, focusing particularly on common primary care issues, family planning and gynecologic needs of women, pregnancy, childbirth, the postpartum period and the care of the newborn” (American College of Nurse-Midwives).
CNMs have a wide range of employment and practice opportunities, including hospitals, independent birthing centers, private practices, health clinics, and in private homes. Job opportunities for midwives at Aurora include the duties of “focusing particularly on prenatal, intrapartal, and post-partal obstetrical services, family planning and gynecological services” (Aurora Health Care). The full Aurora job description can be found in Appendix A.
Autonomy is a central basis for any professional. Autonomy refers to one’s ability for self-determination, with it one decides on a course of action guided by moral, ethical, and legal duties. There are varying levels of autonomy and responsibility in the health care system, depending on educational and employment status. No matter at what level one is employed, every individual is held accountable to the standards of the encompassing organization and regulatory boards. While registered nurses exercise autonomy in their daily tasks their orders are often dictated by higher health care providers. Physicians typically exercise the greatest capacity for autonomy in their practice. CNMs, and other advanced practice nurses, often fall somewhere in between. At Aurora West Allis, CNMs would most likely fall into the base operating core as primary care providers. However, depending on their role, they may fall into the middle line in having some control in policy making in the advanced practice role. One common misconception is that CNMs serve as extensions of physicians or act as paraprofessionals. In contrast to many of the emerging health care provider professions, midwifery has a unique autonomous history independent from medicine. Midwives were once the norm, rather than the exception, in the United States, and still are in most other parts of the world. Where birth is viewed as a natural process, medical intervention is kept at a minimum.
While most CNMs depend on physician services for referrals, consultations, and collaborative management, their scope of practice is highly independent when it comes to patient care. CNMs have expanded their role from solely providing birthing assistance to include primary gynecologic and general women’s health care. CNMs are able to independently see healthy women throughout the life cycle without intervention from physicians and can employ registered nurses and other paraprofessionals for support. As mentioned earlier, CNMs also can carry the authority to diagnose and prescribe medications. Vann (1998) makes known that midwifery has been increasing its position as a safe, accomplished, and preferred women’s provider in the health care community; yet, its appreciation for being an economically advantageous and competitive option if often less heard (p. 41). In March, 2010, the health care reform legislation was passed into action. Under the new reform, reimbursement for CNMs will be covered at 100% of the Part B fee schedule, which is equitable to physician reimbursement. Medicaid will also cover services sought at independent birthing centers (American College of Nurse-Midwives).
Since CNMs and APNs hold a higher practice authority than RNs, they are able to provide high quality, independent care to patients at a lower cost than that of a physician. Despite rising costs and expenditures, there are still barriers to prenatal and postnatal care for women in the United States. One of the major concerns is how to successfully reduce infant and maternal mortalities and morbidities while lowering health care costs. MacDorman and Singh (1998) summarized the works of previous studies that have advocated for the increased utilization of midwives for perinatal care since “women whose pregnancies are managed by midwives generally receive excellent care with lower rates of costly medical interventions such as caesarean section, vacuum and forceps deliveries, induction of labour, ultrasound, and continuous fetal monitoring” (p. 310). CNMs also tend to fill in the sociodemographic gaps in care by taking on patients such as teenage mothers, low income women, women who have not completed high school, and racial/ethnic minorities (p. 310).
Strengths of the CNM role include autonomy, respect, the upholding of the nursing philosophy, and providing safe and economically responsible care to women. With long physician wait times and lack of access to primary care, CNMs can support and provide care to many of the disadvantaged. Midwifery also allows a woman to take charge of her own health and birthing process, taking a less medicalized approach to childbirth. Many of the women who choose a CNM for care and birth are looking for a certain type of care and communication between themselves and their provider. On the other hand, one of the difficulties to increasing the use of midwives is the lack of knowledge surrounding their role in health care. One of the biggest misconceptions is that midwives only perform home births. The reality could not be more contrary. As with many APN roles, the public is simply not aware of their existence or their scope of practice, therefore they are not being utilized to their full potential in the health care community. Another issue in the prevention of midwifery practice is the question of current and previous reimbursement for services. Many insurance companies would not cover the cost of a midwife, past or present; and those that were billed were often billed at a reduced rate or under the partnering physician’s name, also known as billing “incident to,” (American College of Nurse Practitioners). With the new health care reform, the methods of billing will be coming more into line with that of physicians.
Overall, the role of the CNM, in partnership with the women’s pavilion at Aurora West Allis Medical Center, provides exceptional care to women at all stages of development and care.
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