Maternal Care Designation Tips

View all Maternal Designation Tips

• Tip #1: Resuscitation of Maternal Patients

  Tip

  Ensure the hospital has a policy on maternal specific resuscitation, including left uterine displacement and consideration of perimortem cesarean if four minutes of pulselessness has ensued.

  Texas rule

  "The facility shall have written policies and procedures specific to the facility for the stabilization and resuscitation of the pregnant and postpartum patient based on the current standards of professional practice." This rule is relevant to all four maternal levels [§133.206(c)(12); §133.207(c)(14); §133.207(c)(20); and §133.208 (d)(19)].

• Tip #2: Quality Assessment and Performance Improvement (QAPI)

  Tip

  Note that the degree and specificity of the QAPI description is extensive. The state considers this to be one of the most important components of the designation process. There are stipulations as to how the QAPI program should be performed; requirements regarding leadership and oversight; and an expectation that Levels III and IV facilities provide outreach and education, including QAPI, to lower-level facilities.

  Texas Rule

  "[The facility shall have] a Quality Assessment and Performance Improvement (QAPI) Program as described in §133.41 of this title (relating to Hospital Functions and Services). The facility shall demonstrate that the maternal program evaluates the provision of maternal care on an ongoing basis, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until a resolution is achieved. The maternal program shall measure, analyze, and track quality indicators and other aspects of performance that the facility adopts or develops that reflect processes of care and is outcome based. Evidence shall support that aggregate patient data is continuously reviewed for trends and data is submitted to the department as requested ..." [Rule §133.205 (b) (2) (F)]

  Scope of the Rule

  The rule is relevant to all four maternal levels including Rule §133.205 (b) (2) (F) in Designation Requirements which governs all maternal hospitals. There are 17 separate references to the QAPI program in the maternal rules.

• Tip #3: Quality Assessment and Performance Improvement and the Leadership

  Tip

  The maternal medical director and maternal program manager must demonstrate frequent and consistent leadership of the QAPI program.

  Texas Rule

  The maternal medical director (MMD) and maternal program manager (MPM) at all levels are to collaborate with each other on various areas including the Quality Assessment and Performance Improvement (QAPI) program. §133.205(d)(6) and §133.205(e)(4)
  
  The MMD and MPM are both independently responsible to ensure that the QAPI Program is specific to maternal and fetal care, is ongoing, data driven, and outcome based; §133.205(d)(8) and §133.205(e)(6)
  
  At all levels, the MMD demonstrates administrative skills and oversight of the QAPI program; §133.206(b)(2); §133.207(b)(2); §133.208(b)(2); and §133.209(b)(2)
  
  In addition, the levels III and IV facilities provide outreach education to lower level facilities, including the QAPI process. §133.208(a)(7) and §133.209(a)(8)

  Scope of the Rule

  The MMD and the MPM must demonstrate consistent leadership over the QAPI program. This is confirmed by the meeting minutes, which document who led and participated in the maternal quality reviews, hospital maternal quality meetings, or patient safety meetings and whether peer review was conducted. Following an adverse outcome or near miss, the MMD and MPM must demonstrate that they have developed an improvement plan and communicated the interventions (e.g., education, policy, systems) in the plan to medical and hospital staff (including those at bedside). They should also continue to monitor for compliance with new policies and improvement in outcomes. Additionally, leadership at levels III and IV facilities must show that their facilities provide outreach education, including QAPI, to lower-level facilities.

• Tip #4: Quality Assessment and Performance and Key Outcome Measures

  Tip

  Identifying cases of severe maternal morbidity is critical. Consider the CDC's list of 18 severe maternal morbidity indicators and corresponding ICD codes to identify delivery hospitalizations with severe maternal morbidity.

  Texas Rule

  The maternal program shall measure, analyze, and track quality indicators and other aspects of performance that the facility adopts or develops that reflect processes of care and is outcome based. Evidence shall support that aggregate patient data is continuously reviewed for trends, and data is submitted to the department as requested; §133.205(b)(2)(F)
  
  [The responsibilities and authority of the maternal medical director and/or transport medical director shall include] ensuring that the QAPI Program is specific to maternal and fetal care, is ongoing, data driven and outcome based; §133.205(c)(8)

  Scope of the Rule

  The maternal medical director (MMD) and maternal program manager (MPM) must both independently and collaboratively ensure that the maternal QAPI program identifies key quality indicators based on what the facility deems significant as affecting maternal morbidity and mortality. They should set goals, track these indicators, and compare their data to regional or national norms. The quality/safety department should provide timely and meaningful data so that the MMD and MPM can monitor outcomes, quality indicators, and aggregate patient data; develop and implement improvement plans in a multidisciplinary manner; and evaluate implementation until resolution. Additionally, leadership at levels III and IV facilities must show that their facilities provide outreach education, including QAPI, to lower-level facilities.

• Tip #5: The 30-Minute Rule

  Tip

  Hospitals must define urgent requests and actively monitor and document provider response times to urgent requests, as there are 23 separate references in the Texas rule requiring a provider to arrive at a bedside within 30 minutes of an urgent request. The hospital should be able to show clear evidence of tracking response times and all personnel involved in maternal care should understand the criteria of what qualifies as an urgent request.

  Texas Rule

  The 30-minute rule applies to every level of care. At all levels there are rules specific to primary physicians, mid-level providers (as applicable), backup providers, and anesthesia personnel. Levels II through IV have requirements for obstetrician–gynecologists and medical and surgical physicians, and levels III and IV have requirements for maternal-fetal medicine specialists.

  Scope of the Rule

  During the Department of State Health Services' (DSHS) provider webinars, staff have been clear that facilities must actively monitor 30-minute response times and document compliance. This is especially important when there are urgent situations that may compromise the safety and well-being of the patient (mother or fetus). It is critical that staff monitor the arrival of the appropriate provider to ensure the best care for the patient.

• Tip #6: Defining an Urgent Response

  Tip

  Hospitals should have a policy that defines urgent (versus emergency) clinical situations, including a policy for notification and expectation of arrival at the patient's bedside, in all areas where maternal patients receive care. This includes OB triage, labor and delivery, the postpartum floor, operating rooms, the emergency department, the ICU, and other patient floors where maternal patients may be located. All staff should know the policy and receive education on how to contact the appropriate provider and document accurately. The hospital should be able to show clear evidence of monitoring whether clinical situations were recognized as urgent and appropriate communication to the provider occurred.

  Texas Rule

  The 30-minute rule applies to every level of care. At all levels there are rules specific to physician primary providers, mid-level providers as applicable, backup providers, and anesthesia personnel. Levels II through IV have requirements for obstetrician–gynecologists and medical and surgical physicians, and levels III and IV have requirements for maternal-fetal medicine specialists.

  Scope of the Rule

  During the Department of State Health Services' provider webinars, staff have been clear that facilities must define the situations that require an urgent response (within 30 minutes) to the bedside. One way to define this for various settings is to use a general definition such as "patient status or condition(s) in which there is a reasonable likelihood of morbidity, mortality, or both if the patient is not evaluated and managed quickly." Staff should be educated, ensuring competency on an annual basis, and optimally reinforced with team-based training. It is critical that the hospital monitor compliance using triggered and random chart reviews to assess recognition of urgent clinical situations and conduct a monthly QAPI review of noncompliances regardless of outcome.

  Key Definitions

  • Urgent situation: Patient status or condition(s) in which there is a reasonable likelihood of morbidity, mortality, or both if not evaluated and managed within 30 minutes
  • Urgent request: Communication from hospital staff to a provider to convey the patient's urgent status or condition
  • Emergency situation: Patient status or condition(s) in which there is a reasonable likelihood of morbidity, mortality, or both if not evaluated and managed immediately, meaning without delay
• Tip #7: Behavioral Health

  Tip

  All levels must have a behavioral health professional available at all times for consultation as appropriate to the patient population served. Note that "appropriate to the patient population served" means having awareness of the common behavioral conditions or emergency conditions that may arise (e.g., depression, suicide, psychosis, substance use disorder).
  
  Levels III and IV facilities have higher requirements for availability to arrive in person, and in level IV facilities, a psychiatrist with experience in maternal counseling is required. Please refer to the rules for specific requirements. Your facility should have written guidelines or protocols that describe the conditions under which a behavioral health consultation is required as well as recommended. Records should document when a consultation is requested, when the consultation or on-site visit takes place, and the outcome.

  Texas Rule

  There are eight separate references in the Texas rule that address the requirement for a behavioral health professional: §133.206 (c)(4), §133.207 (c)(6), §133.203 (c)(3)(B), §133.203 (c)(4)(B), §133.208 (a)(2), §133.208 (d)(8), §133.209 (a)(2), and §133.209 (c)(8)(A).

  Scope of the Rule

  Unless otherwise specified, the behavioral health professional does not need to be a psychiatrist or psychologist, but must demonstrate training or experience in maternal counseling or both. The Department of State Health Services' provider webinars have more information about this requirement.

• Tip #8: Team-based Training

  Tip

  Perform drills together! Team-based training is critical to preparing medical, nursing, and ancillary staff for emergencies. Training should be multidisciplinary and involve both hospital and medical staff. Your hospital's policy on team-based training should include the rationale for which exercises are chosen; frequency of training; medical, nursing, and other staff who participate; and criteria for verification of competence.
  
  Following a training, your hospital's documentation should include the drill performed (including purpose and competency measures), roster documenting participation, educational materials, and policy stating the consequences for noncompliance.

  Texas Rule

  All levels require that "maternal medical staff will participate in ongoing staff and team-based education and training in the care of the maternal patient." For additional details, please refer to the Texas rules and review the Department of State Health Services' provider webinars.

  Scope of the Rule

  The rule has two key requirements: that drills must be ongoing, regular, and sufficient in clinical scope; and that documentation show that all active medical staff and hospital staff demonstrate necessary competencies. Team-based training should take place in all areas where maternal patients receive care. This includes OB triage, labor and delivery, the postpartum floor, operating rooms, the emergency department, the ICU, and other patient floors where maternal patients may be located.

• Tip # 9: Outreach and Education

  Tip

  Outreach education and assistance with quality improvement by higher level facilities with hospitals in their regional system is a significant component of regionalized maternal care. Level III and Level IV facilities should work collaboratively with hospitals to identify their needs. Hospital education must include training for quality improvement initiatives. This could include components such as: setting well-defined thresholds for transfer to the higher-level facility and reviewing transfers for issues, including improved recognition of a complicated condition; better patient stabilization; more detailed documentation; or earlier consultation.

  Texas Rule

  Per General Requirements §133.203 (c)(3)(G) and §133.203 (c)(3)(H), Level III and Level IV facilities must "provide outreach education to lower level designated facilities, including the Quality Assessment and Performance Improvement (QAPI) process."

  Scope of the Rule

  Show that you've met this requirement by documenting your plan, dates, activities accomplished, and roster of attendees. QAPI minutes should include details on how topics and activities were identified and will address needs of the facility receiving the education and training. For additional details, please refer to the Texas rules and review the Department of State Health Services' provider webinars.

• Tip #10: Developing Collaborative Relationships in Your Perinatal Care Region

  Tip

  Collaborate with facilities in your perinatal care region. Doing so can contribute to significant improvements in systems of care and facilitate quality improvement efforts based on the resources, opportunities, and needs specific to the region.

  Texas Rule

  There are two separate references in the Texas rule that require the maternal medical director (MMD) and maternal program manager (MPM) to develop collaborative relationships with their counterparts in the Perinatal Care Region: §133.205 (d)(11) and (d)(7). For additional details, please refer to the Texas rules and review the Department of State Health Services' (DSHS) provider webinars.

  Scope of the Rule

  Although not specified in the rule, DSHS has stated that working with other MMDs and MPMs within the same hospital system does not meet the rule. Hospitals must demonstrate that their MMD and MPM have collaborative relationships with their counterparts in other regional hospitals. While the rule doesn't define the nature of the collaboration, the implication is that the purpose of the collaboration is improved patient care.

• Tip #11: Pharmacy Services

  Tip

  Include pharmacy representatives in your QAPI meetings, especially in cases that involve a medication issue. They can provide ongoing education of new medications and discuss medication issues. For Levels III and IV facilities, request in-services about maternal-specific pharmacological issues and treatment considerations for critically ill women.

  Texas Rule

  §133.41 of the Texas Administrative Code specifies that the hospital must have a pharmacy licensed by the Texas State Board of Pharmacy, directed by a licensed pharmacist, and a description of oversight, organization, storage, documentation, staffing, and QAPI. Level-specific pharmacy requirements for maternal facilities are as follows:
  
  Level I §133.206 (c)(10) and Level II §133.207 (c)(12): "Appropriate anesthesia, laboratory, pharmacy . . . shall be available on a 24-hour basis as described in §133.41 of this title (relating to Hospital Functions and Services) respectively."

  Level III §133.208 (d)(17) and Level IV §133.209 (d)(16): "Pharmacy services shall comply with the requirements found in §133.41 of this title and shall have a pharmacist with experience in perinatal pharmacology available at all times."

  Scope of the Rule

  Levels III and IV facilities must have a licensed pharmacist with experience in perinatal pharmacology available (by phone) at all times. In addition, all pharmacies should ensure emergency access to medications such as uterotonic agents in the event of postpartum hemorrhage and antihypertensive medications for severely elevated blood pressures. For additional details, please refer to the Texas rules and review the Department of State Health Services' provider webinars.

• Tip #12: Preliminary Reading of Imaging Studies

  Tip

  Hospitals without a radiologist available at all times to read imaging studies should define those circumstances in which preliminary reading of imaging studies are done. Facilities should define provider qualifications, scope of the imaging procedures appropriate for preliminary reads, circumstances in which an urgent formal reading is required, documentation standards, random monitoring of charts, and quality review with the director of radiology. Document the monitoring results in the monthly QAPI minutes.

  Texas Rule

  Level I §133.206 (c)(10)(C)(i) and (ii) and Level II §133.207 (c)(14)(D)(i) and (ii) address the documentation, reconciliation, and QAPI of preliminary reading of imaging studies.
  
  i. "If preliminary reading of imaging studies pending formal interpretation is performed, the preliminary findings must be documented in the medical record."
  ii. "There shall be regular monitoring of the preliminary versus final reading in the QAPI Program."

  Scope of the Rule

  While not stated in the rules, there is an assumption that level III and IV facilities have a radiologist available at all times to perform formal reading of imaging studies; however, if preliminary reading is performed, then the facility should have a policy regarding preliminary and formal interpretation and apply the same requirements as level I and II facilities.
  
  Also, please note that imaging technicians (x-ray or ultrasound) are not qualified for interpretation; even preliminary readings require a provider to interpret. For additional details, please refer to the Texas rules and review the Department of State Health Services' provider webinars.

• Tip #13: Defining Scope of Services

  Tip

  Ensuring that your patients receive risk-appropriate maternal care is a key strategy for decreasing maternal morbidity and mortality. As a first step, define your hospital's scope of services to gain a clear understanding of its capabilities and the types of conditions or complications that the facility is able to manage. Consider its medical and support personnel; equipment; and aspects such as location, availability of transport, and access to resources in the local or regional area.
  
  Next, define those circumstances in which pregnant and postpartum patients should be transferred to a health care facility that offers a higher level of care. Initiate conversations with facilities of differing levels to develop relationships for consultation, referral, and transfer. (See Tip #10: Developing Collaborative Relationships in Your Perinatal Region for more information.) Institute procedures for transfer in your hospital and communicate these procedures to all personnel.
  
  Collaboration between hospitals helps ensure that all maternity hospitals have the personnel and resources for unexpected obstetric emergencies and that consultation and referral are available if a patient needs high-risk care.

  Texas Rule

  §133.205(b) designation requirements for all levels (I to IV): "Program Plan. The facility shall develop a written plan of the maternal program that includes a detailed description of the scope of services available to all maternal patients, defines the maternal patient population evaluated and/or treated, transferred, or transported by the facility, that is consistent with accepted professional standards of practice for maternal care, and ensures the health and safety of patients."

  Scope of the Rule

  Document the scope of services provided to maternal patients in detail and monitor, on an ongoing basis, that capabilities are current. Review cases in which patients who have conditions outside the scope of services remain in the hospital and timeliness of transfers out to and in from other hospitals. The hospital should be able to show that staff know the scope of maternal services and the circumstances for transfer and that staff comply with the hospital's procedures.

• Tip #14: Documentation of Training, Competency, and Continuing Education (Part 1)

  Tip

  Define, monitor, and assure that your hospital's personnel has the training, competency, and ongoing education that is required to care for the scope of patients. The program plan should clearly delineate the scope of services for maternal care, including the complexities, and how various personnel will care for these patients. (See Tip #13: Defining Scope of Services more information.)

  Texas Rule

  Level I, §133.203 (c)(1)(B): Maternal designated facility will "have skilled personnel with documented training, competencies and annual continuing education specific for the patient population served." This is reiterated for level II, §133.203 (c)(2)(B); level III, §133.203 (c)(3)(E); and level IV, §133.20
  3 (c)(4)(F).

  The requirement is further is amplified by the following designation requirements:

  • §133.205 (b)(2)(H): the facility is required to have "provisions for providing continuing staff education, including annual competency and skills assessment that is appropriate for the patient population served; the oversight for these training, competencies and annual continuing education is clearly the [Maternal Medical Director (MMD)] and the [Maternal Program Manager (MPM)], together and separately."
  • §133.205 (d)(6): "[MMD] collaborating with the MPM in areas to include: developing and/or revising policies, procedures and guidelines, assuring medical staff and personnel competency, education and training; and the QAPI Program."
  • §133.205 (e)(4): "[MPM] collaborates with the MMD in areas to include: developing and/or revising policies, procedures and guidelines; assuring staff competency, education, and training and the QAPI Program."

  Scope of the Rule

  Maternal staff (including physician and nursing staff) requirements, training, annual continuing education, and competency assurance should be delineated and tracked. For example, labor and delivery nurses should have regular competency training in fetal heart rate monitoring that is specifically delineated, communicated, and monitored. Your hospital's documentation should include the training performed (including purpose and competency measures), roster documenting participation, educational materials, and policy addressing noncompliance.

• Tip #15: Documentation of Training, Competency, and Continuing Education (Part 2)

  Tip

  The maternal designation rules require annual competencies and education to ensure continuous competency in clinical care. Be sure that all maternal medical staff meet the requirement, and document 100% participation of maternal medical staff in trainings and educational activities. Include the educational requirement met, participation in team-based trainings, and competency obtained.

  Texas Rule

  §133.205 (c)(2): For all levels, the maternal medical staff will participate in ongoing staff and team-based education and training in the care of the maternal patient. The requirement is further supported by the following requirements:

  • §133.205 (d)(2): "[Maternal medical director (MMD)] assuring maternal medical staff competency in managing obstetrical emergencies, complications and resuscitation techniques"
  • §133.205 (d)(6): "[MMD] collaborating with the maternal program manager in areas to include: developing and/or revising policies, procedures and guidelines, assuring medical staff and personnel competency, education and training; and the QAPI Program" 

  The education must include "complicated conditions" for level I and II primary providers and "complicated and critical conditions" for level III and IV primary providers.

  • For level I and II hospitals, primary maternal providers "shall complete annual continuing education, specific to the care of pregnant and postpartum patients, including complicated conditions." §133.206 (c)(6)(B) and §133.207 (c)(8)(B) 
  • For level III and IV hospitals, primary maternal providers "shall complete annual continuing education, specific to the care of pregnant and postpartum patients, including complicated and critical conditions." §133.208 (d)(10)(B) and §133.209 (d)(9)(B)

  Scope of the Rule

  Medical staff requirements, training, annual continuing education, and competency assurance should be delineated and tracked with the MMD's oversight. You may recall that Tip #14 addressed requirements for nursing staff. Individual hospitals set requirements, but at a minimum, each member of the maternal medical staff, including obstetric providers and nurses, must participate in at least one team-based drill and fulfill the annual education requirement. The scope of the education and team training must include complex conditions for all levels and critical conditions for level III and IV hospitals. As you consider these requirements, Tip #8, Team-based Training, may be helpful.

• Tip #16: Plan of Correction

  Tip

  When deficiencies are identified during the site survey, the hospital must include a plan of correction (POC) with the designation application to the state. We encourage hospitals to have an organized debriefing session immediately after the survey is completed (or the next morning) to review the deficiencies identified and how these issues will be resolved. The POC, signed by the maternal medical director, maternal program manager, and chief executive officer, needs to include those items in the Texas survey audit form identified as noncompliant and any findings from the chart audit. Keep in mind that the POC should be more than simply a table or spreadsheet with the necessary components. Ideally, include documentation on completion or implementation of the corrective action, such as meeting minutes or a newly approved policy. See our sample template to get started.

  Texas Rule

  §133.204 (a): For all levels, the applicant shall submit the packet that includes the following documents to the Office of EMS/Trauma Systems within 120 days of the facility's survey date:

  • §133.204 (a)(4): a plan of correction (POC), detailing how the facility will correct any deficiencies cited in the survey report, to include: the corrective action; the title of the person responsible for ensuring the correction(s) is implemented; how the corrective action will be monitored; and the date by which the POC will be completed

  Scope of the Rule

  The application is due to the Texas Department of State Health Services (DSHS) within 120 days of the site survey, so although a plan needs to be in place to address all of the deficiencies, some processes (such as QAPI) may take longer to fully reach compliance. Please note that per their webinars, Texas DSHS determines the criteria for compliance with a rule, so they may identify additional areas that they'd like the hospital to address. Therefore, staff should take notes throughout the survey, including the tour, interviews, and debriefing session(s). In addition, we encourage each hospital to correspond with Texas DSHS to ensure its POC meets the requirements.

• Tip #17: Medical and Surgical Specialists and Subspecialists

  Tip

  Each level of maternal care describes the minimum capabilities related to health care provider availability and facility resources, and each higher level of care includes and builds on the capabilities of the lower levels. With levels of maternal care defined, hospitals can ensure that they have the equipment, personnel, infrastructure, and consultants to care for the complexity of the patient population served. Notably, the Texas Department of State Health Services does not define the specific medical and surgical specialists and subspecialists that are required. However, the levels of maternal rules provide some language for each hospital level.

  Texas Rule

  • Level I: “Medical, surgical and behavioral health specialists shall be available at all times for consultation appropriate to the patient population served.” There is not a requirement for arriving to the bedside within a certain time for an urgent request; the “available” definition is for consultation which may be by telephone or telemedicine. §133.206 (c)(4)
  • Level II: “Medical and surgical physicians shall be available at all times and arrive at the patient bedside within 30 minutes of an urgent request.” §133.207 (c)(5)
  • Level III: “Medical and surgical physicians, including critical care specialists, shall be available at all times and arrive at the patient bedside within 30 minutes of an urgent request.” §133.208 (d)(7)
  • Level IV: “Ensure access to on-site consultation to a comprehensive range of medical and maternal subspecialists, surgical specialists and behavioral health specialists.” Also, a level IV facility must have “a comprehensive range of medical and surgical critical care specialists and advanced subspecialists on the medical staff.” §133.209 (a)(2) and §133.209 (d)(5)(A)

  Scope of the Rule

  To determine which medical and surgical specialists and subspecialists are needed, it may be helpful for level III and IV facilities to define their patient population and review data on maternal morbidity and mortality over the past five to seven years to determine what types of conditions would most likely affect their patients. They should compare their own population to regional and statewide data to see what complications are commonly encountered in their facility and their region. This helps hospitals anticipate the type of complex and critically ill patients who could be admitted to their ICU.
  
  To assist hospitals in thinking about this process, these are two hypothetical hospital examples with suggested specialists and subspecialists based on the medical conditions and patient population treated by these hospitals.

  Example #1

  Hospital A, a Level III facility, has maternal patients who are treated in the ICU with sepsis, acute kidney injury, hemorrhage and DIC, pulmonary problems, congestive heart failure, and sometimes diabetic ketoacidosis. Not uncommonly, the maternal patients have neurological diseases. Based on this patient population, Hospital A has decided to have the following medical specialists and subspecialists. Please note that those specialists not selected could be considered, but do not represent the specialists needed for the patient population served by this hospital.

  Medical Specialists/Subspecialists
  Internal Medicine	X
  Allergy/ Immunology
  Cardiology	X
  Endocrinology	X
  Gastroenterology	X
  Hematology/Oncology	X
  Infectious disease	X
  Medical genetics
  Nephrology	X
  Pulmonary medicine	X
  Pulmonary and critical care medicine	X
  Rheumatology
  Sleep medicine
  Transplant medicine
  Neurology	X
  Physical medicine and rehabilitative medicine	X

   

  Example #2

  Hospital B, a Level IV facility, has very complex and critically ill maternal patients who are treated in the ICU with typical conditions. Additionally, this hospital receives referrals for maternal patients who have neurological diseases, cardiovascular diseases, ENT conditions, and vascular diseases. The facility also performs transplants. Based on this patient population, Hospital B has decided to have the following surgical specialists and subspecialists.

  Surgical Specialists/Subspecialists
  General Surgery	Otolaryngology
  Colon and rectal surgery	Pediatric surgery (morelikely a NICU requirement)
  Critical care surgeon	Thoracic surgery
  Neurological surgery	Transplant surgery
  Ophthalmological surgery	Trauma surgery
  Oral and maxillofacial surgery	Vascular surgery
  Orthopedic surgery	Urological surgery

  
  
• Tip #18: Family-Centered Philosophy

  Tip

  Maximizing a family's time with their newborn is critically important to outcomes such as bonding and successful breastfeeding. Therefore, hospitals should consider their approach to family-centered care. Examples of family-centered care include:

  • Conducting newborn exams at the patient's bedside rather than the nursery. This encourages bonding and allows parents to ask questions and participate in the examination process.
  • Rooming in. This increases the parents' confidence in caring for their infant and provides an opportunity to ask questions about their infant and self-care.
  • Ensuring skin-to-skin contact in the OR, which helps facilitate bonding.
  • Implementing the "golden hour," which is uninterrupted skin-to-skin bonding and early breastfeeding in the first hour after birth.
  • Special attention and support to women who are separated from their infants after delivery; for example, if the mother is admitted to the ICU or infant to the NICU or the mother or infant is transferred to another facility.

  Texas Rule

  §133.205 (a): "Designated facilities shall have a family centered philosophy. The facility environment for perinatal care shall meet the physiologic and psychosocial needs of the mothers, infants, and families. Parents shall have reasonable access to their infants at all times and be encouraged to participate in the care of their infants."

  Scope of the Rule

  This requirement is applicable for all levels, so hospitals should be prepared to demonstrate how their facility supports a family-centered philosophy and describe that approach in the program plan.

• Tip #19: Chart Audit, Part 1

  Tip

  The patient record review during the site survey is an important component to evaluating the facility's compliance with the designation criteria. As part of its quality assurance and performance improvement process, the facility should assess its medical records as issues are identified and also perform random chart audits to ensure compliance with their policies and guidelines and, as appropriate, the Texas rules. Reviewing records can also help locate opportunities to improve a flagged outcome; for example, a chart flagged for shoulder dystocia should also be reviewed for family-centered care, behavioral screening, lactation education, dietary consultation, and communication. Hospital staff should be prepared to demonstrate that they performed their own quality reviews of charts.

  Texas Rule

  §133.210 (d)(1): The survey team shall evaluate the facility's compliance with the designation criteria by "reviewing medical records; staff rosters and schedules; documentation of QAPI Program activities, including peer review; the program plan; policies and procedures; and other documents relevant to maternal care"

  Scope of the Rule

  At the direction of Texas Department of State Health Services, during the site visit, each surveyor randomly reviews 10 records of the total records identified based on the list of conditions provided in advance to the facility. Surveyors review the charts for compliance to the designation rules; assess whether protocols and procedures were followed; and consider other systematic issues, such as nurses' recognition of urgent situations, notification of provider, arrival of provider at the bedside, appropriate assessment and intervention, and documentation of these items.

• Tip #20: Chart Audit, Part 2

  Tip

  Reviewing charts to assess for staff and providers compliance with your facility's policies and procedures is an important part of your quality assurance and performance improvement process. With so many guidelines and procedures, it may be helpful to prioritize those that most significantly affect patient care and outcomes. As you review charts, it is important to document specific elements, including the rationale for choosing these areas to monitor, the findings from chart audits, the interventions to improve compliance, the plan for monitoring improvement, and the evaluation of that monitoring.

  Texas Rule

  §133.205 (b)(2)(A): The written maternal program plan shall include, at a minimum: Program policies and procedures that are "(i) based upon current standards of maternal practice; and (ii) adopted, implemented and enforced for the maternal services it provides"

  Scope of the Rule

  During a site visit, surveyors will review charts for compliance by staff and providers to a hospital's policies. Following the survey, facilities should regularly audit charts to ensure that staff and providers are compliant with policies and guidelines as part of its quality assurance and performance improvement process.

• Tip #21: Chart Audit, Part 3 (Closing the Loop)

  Tip

  When a chart audit uncovers issues, the information needs to be communicated back to the providers and staff in a way that is effective, timely, and specific, while respecting sensitivity and confidentiality of those involved.

  Texas Rule

  §133.205 (b)(2)(A): The written maternal program plan shall include, at a minimum:
  Program policies and procedures that are "(i) based upon current standards of maternal practice; and (ii) adopted, implemented and enforced for the maternal services [they provide]"

  Scope of the Rule

  The facility's written program plan shall have policies and procedures that are based on current standards of maternal practice and are adopted, implemented, and enforced by the facility. Chart audits done by the facility as part of its quality assurance and performance improvement program are the best method to identify when policies and procedures are not followed. Any issues identified should be communicated back to the staff in a manner that provides specificity and context without being punitive or blaming. Case reviews are a powerful and effective tool in illustrating concepts, as long as they're presented within a culture of collaboration rather than an environment in which there is blame and hostility. In a negative environment, staff will not feel empowered to communicate issues, and problems will continue.

• Tip #22: Perinatal Staff, Nurse Representative

  Tip

  Ensure that a perinatal staff registered nurse serves on the hospital's nurse staffing committee. The nurse representative from the perinatal area represents all maternal areas, such as triage, labor and delivery, postpartum antepartum, operating rooms, and ICU, and should have sufficient experience and seniority to be respected by peers and serve as a respected member of the nursing leadership.

  Texas Rule

  §133.205 (b)(2)(I): "a perinatal staff registered nurse as a representative on the nurse staffing committee under §133.41 of this title"

  Scope of the Rule

  This rule requires that hospitals have a process for encouraging input from nurses regarding the number of staff members and skill mix needed to provide care for a given patient volume, complexity, and acuity. The facility, usually led by the chief nursing officer or maternal program manager, should ensure that the designated nurse representative is able to attend most meetings and has sufficient experience, seniority, and assertiveness to advocate for the maternal area and communicate concerns of floor nurses and maternal nursing leadership. Hospitals can show compliance with this requirement by documenting the nurse representative's participation in the staffing committee minutes. If possible, it is also optimal for the nurse representative to document the feedback received from the nurses in the various maternal areas. The chief nursing officer or maternal program manager should establish a process to assess if the perinatal staffing nurse representative has fulfilled the expectations of this role.

• Tip #23: Observing a Survey

  Tip

  If you are in a health system, consider observing a maternal verification survey at another hospital within your system before your own hospital is surveyed. The survey includes medical record review, dinner meeting, interviews, facility tour, and opening and closing sessions. By observing a survey, you can better understand this process, how to organize materials, and how to document performance of various functions, such as the quality assessment and performance improvement (QAPI) program, team-based education, and resuscitation.

  For example, during a chart audit, surveyors will need to reference the hospital's policies and procedures. It is optimal for the hospital to print the policies and organize them in a binder in a logical or alphabetical order for surveyors to easily access. Another key area is the maternal QAPI program. By observing the discussion of the hospital's QAPI process, the observer may gain important clarity about how to better organize their own QAPI. If you are interested in observing a survey within your health system, please contact Stacy Andries at [email protected].

  Texas Rule

  §133.210 (d) The survey team shall evaluate the facility's compliance with the designation criteria by:

  1. Reviewing medical records; staff rosters and schedules; documentation of QAPI Program activities, including peer review; the program plan; policies and procedures; and other documents relevant to maternal care;
  2. Reviewing equipment and the physical plant;
  3. Conducting interviews with facility personnel and surveyors may meet privately with individuals or groups of personnel; and
  4. Evaluating appropriate use of telemedicine capabilities where applicable.
• Tip #24: The Navigators

  Tip

  During a site survey, assign skilled navigators to assist the survey team in their chart review. Surveyors review a minimum of 10 charts each, and since most of the medical records are electronic, skilled navigators are critical in helping surveyors access key documents. These documents may include history and physical examination, progress notes, consent forms, antepartum records, memorandums of transfer, operative and delivery reports, lab reports, vital signs, pathology reports, imaging reports, nursing notes, and discharge notes. Navigators should also be able to access information that may be on a separate system. For example, if the surveyor needs to compare provider and nursing notes side-by-side with the fetal heart rate monitoring strip, but the fetal heart rate monitoring strip is on a separate system, the navigator should be able to cross-reference fetal heart pattern with nursing documentation.

  Texas Rule

  §133.210 (d) The survey team shall evaluate the facility's compliance with the designation criteria by:

  1. Reviewing medical records; staff rosters and schedules; documentation of QAPI Program activities, including peer review; the program plan; policies and procedures; and other documents relevant to maternal care;
  2. Reviewing equipment and the physical plant;
  3. Conducting interviews with facility personnel and surveyors may meet privately with individuals or groups of personnel; and
  4. Evaluating appropriate use of telemedicine capabilities where applicable.

  Scope of the Rule

  Since the chart audit is a critically important part of the site survey, the navigator's role is very important to help the survey team find the necessary information. For example, if the surveyor needs to find documentation on lactation counseling and the navigator doesn't know where that note is found, the facility may potentially be found noncompliant in this area. The additional challenge with medical records is that staff likely have different access or views to some medical records, so navigators can prepare for the chart audit with nurses, quality staff, and physicians to ensure that all documentation needed to show compliance is accessible to the surveyors.

• Tip #25: ICU and Maternal Nursing

  Tip

  Optimize care of maternal patients in the ICU by supporting collaboration between the ICU and obstetric teams. When pregnant or postpartum patients are admitted to the ICU, the role of the obstetric team depends on multiple factors, including the patient's status (antepartum or postpartum) and the ICU model (open or closed). Even with different responsibilities, it's critical for patient care to be done collaboratively by a multidisciplinary care team, especially the ICU nurses and maternal nurses. Importantly, because of the critical nature of the patients, generally the maternal nurse should be a labor and delivery nurse with sufficient experience and training in complex conditions. While the ICU nurse may, for example, manage ventilator and vasopressor drips and interpret ECG monitors, and the maternal nurse may, for example, assess the fetal heart rate pattern and monitor for uterine atony or vaginal bleeding, this distinct "division of labor" often allows problems to go unrecognized.

  Texas Rule

  The coordination of nursing care is specifically described in the level III and level IV maternal designation requirements.

  • §133.208 (d)(6) Maternal Designation Level III: Intensive Care Services. The facility shall provide critical care services for critically ill pregnant or postpartum patients, including fetal monitoring in the ICU, respiratory failure and ventilator support, procedure for emergency cesarean, coordination of nursing care, and consultative or co-management roles to facilitate collaboration.
  • §133.209 (d)(7) Maternal Designation Level IV: Management of critically ill pregnant or postpartum patients, including fetal monitoring in the ICU, respiratory failure and ventilator support, procedure for emergency cesarean, coordination of nursing care, and consultative or co-management roles to facilitate collaboration.

  Scope of the Rule

  Management of pregnant and postpartum women in the ICU can be complex. However, by understanding important critical care or maternal practices in caring for a pregnant or postpartum woman and engaging in continuous communication and coordination, ICU and maternal nurses can better optimize care and avoid risks of adverse outcomes. For example, the maternal nurse understands some of the physiology, side effects, and risks of mechanical ventilation and is alert for a complication such as right mainstem intubation or pneumothorax. Correspondingly, the ICU nurse is aware of some of the physiological changes in pregnancy, such as respiratory alkalosis and can interpret arterial blood gas levels. This overlap in knowledge and coordination can be viewed as two hands with interconnected fingers, rather than fingertips touching; with the former, the patient has safer care.

  Practical tips for how a hospital may initially set up its ICU and maternal nurse coordination:

  • Schedule quality assessment and performance improvement meetings that include ICU and maternal staff to discuss management of maternal patients in the ICU.
  • Discuss the critical care and physiologic considerations in caring for these patients.
  • Define common conditions requiring ICU admission of maternal patients. Discuss complications and early warning signs.
  • Develop an early warning system and define communications channels. Monitor to ensure the system and documentation are being performed consistently and accurately.
• Tip #26: Maternal Sepsis

  Tip

  Hospitals should have a maternal-specific guideline or policy on the early recognition, risk stratification, diagnosis, and management of sepsis in maternal patients. Nationally, sepsis is a leading cause of maternal death, with pneumonia, pyelonephritis, and endometritis as the most common causes of sepsis. The normal physiological changes in pregnancy make the diagnosis and management of sepsis in the pregnant or postpartum patient more difficult. Some of these changes include an expanded plasma volume, relative immunosuppressed state, respiratory alkalosis and less capacity to buffer metabolic acidosis, and competing demands of the fetus and pregnant patient. In addition, the higher baseline heart rate can complicate the early recognition of sepsis. With the potential for significant adverse outcomes, it is not only critical for hospitals to have a maternal-specific policy for sepsis but also that leadership educate staff on early recognition and treatment.

  Texas Rule

  "For all maternal designation levels, the facility shall have written guidelines or protocols for various conditions that place the pregnant or postpartum patient at risk for morbidity and/or mortality, including promoting prevention, early identification, early diagnosis, therapy, stabilization, and transfer. The guidelines or protocols must address a minimum of: (D) sepsis and/or systemic infection in the pregnant or postpartum patient;" §133.206 (c)(13)(D); §133.207 (c)(15)(D); §133.208 (d)(21)(D); §133.209 (d)(20)(D)

  Scope of the Rule

  The Texas maternal designation rules specify that all levels (I through IV) must have policies or guidelines regarding sepsis in the maternal patient that include prevention, early identification, early diagnosis, therapy, stabilization, and transfer. A hospital may choose to have a separate policy or protocol for sepsis in maternal patients or include a subsection within their single sepsis policy. However, it is important that there is at minimum, a maternal-specific section. Although there has been lack of robust research detailing care of the maternal patient with sepsis, there are some areas that hospitals may consider including in their policy:

  • Using the Modified Early Warning Scoring Systems or the Sepsis in Obstetrics Score, as these tools have been proposed to screen for and identify sepsis in maternal patients
  • Using prevention measures, such as screening for and treating asymptomatic bacteriuria, and encouraging pregnant patients to receive an annual influenza vaccine
  • Describing how fetal status would be monitored
• Tip #27: Maternal Medical Director and Maternal Program Manager: Collaboration Within the Perinatal Care Region

  Tip

  Hospitals should support their maternal medical director (MMD) and maternal program manager (MPM) in developing collaborative relationships with their counterparts in designated facilities within their perinatal care region (PCR). This collaboration is separate from the requirement for each facility to participate in their applicable PCR. Per the Department of State Health Services' provider webinars, hospitals must demonstrate that their MMD and MPM have collaborative relationships with their counterparts in other regional hospitals.

  Texas Rule

  For all maternal designation levels, there are two separate references in the Texas rule that require the MMD and MPM to develop collaborative relationships with their counterparts in the PCR: §133.205 (d)(11) and (e)(7).

  Scope of the Rule

  This rule aims to foster collaboration among facilities of differing levels of maternal care within a PCR to improve systems of care and facilitate quality improvement efforts based on the resources, opportunities, and needs specific to the region. While the rule does not provide further detail about the degree of collaboration or regularity, consider how your hospital can establish and sustain meaningful relationships with other facilities and develop and implement a plan. Show that you've met this requirement by documenting your plan, dates, activities accomplished, and roster of attendees. Here are some examples to consider. 

  • Example #1: While attending the regional advisory council meetings, the MMD and MPM from a level III hospital plan regular meetings with several MMDs and MPMs from three hospitals outside their system to share ideas on supporting QAPI activities in their level I and II system's hospitals that seem to be struggling. Please note that attendance by alternate hospital staff does not meet this requirement. The MMDs and MPMs must be present. 
  • Example #2: The MMD and MPM of a facility reach out to the hospitals outside their system that transfer patients to their hospital to discuss how to improve communication and perhaps even joint QAPI for transferred patients. These discussions occur bimonthly or quarterly depending on the volume of patients and are done through phone or video. Documentation includes participant names, general topics, and hospitals represented.
  • Example #3: The level III and IV hospitals in the PCR develop a quality improvement forum and their MMDs and MPMs engage in monthly or bimonthly telephone conference calls to discuss various topics relevant to care of complex patients. Hospitals alternate presenting topics and participants share best practices. The meetings are documented, and all participants get credit.
  • Example #4: The MMD at a level III hospital has regular meetings with the MMDs at several level II hospitals that aren't in the same health system but are in the same PCR. They discuss during telephone meetings how to best implement their AIM bundles and overcome barriers. These meetings are documented and occur in addition to their normal participation in AIM sessions.
• Tip #28: COVID-19 Update-Developing Collaborative Relationships within the Perinatal Care Region

  Tip

  The COVID-19 crisis is an important time for the maternal medical directors (MMDs) and maternal program managers (MPMs) in each perinatal care region (PCR) to collaborate with their counterparts to share information, identify best practices, and coordinate plans to facilitate transfers of maternal patients.

  Texas Rule

  For all maternal designation levels, there are two separate references in the Texas rule that require the MMD and MPM to develop collaborative relationships with their counterparts in the PCR: §133.205 (d)(11) and (e)(7).

  Collaborative Effort

  PCRs around the state are conducting regular webinars or calls with their MMDs and MPMs to address challenges in caring for patients during the COVID-19 pandemic. For example, the MMDs and MPMs at hospitals in the Southeast Texas Regional Advisory Council participate in a webinar every Monday morning. The webinar consists of two parts. 

  Part I (20 minutes) 

  Maternal workgroup leaders provide an update on current clinical information and resources and conduct polling to get an estimate of the number of COVID-positive patients and persons under investigation and critically ill COVID-positive maternal patients.

  During the discussion, speakers have covered the following topics:

  • How to don and doff personal protective equipment (PPE) correctly
  • Sample triage processes
  • Counseling maternal patients
  • Respiratory assessment of maternal patients and the physiological differences from nonpregnant patients
  • Proning pregnant patients
  • Obtaining nasopharyngeal sampling correctly
  • Advocating for sufficient PPE for maternal staff and physicians
  • Engagement with neonatal and pediatric staff
  • Documentation and legal concerns

  Part II (40 minutes)

  The MMD and MPM from every hospital of the PCR describe their experiences, best practices, lessons learned, challenges, and questions. It is a collaborative discussion during which the other maternal leaders help solve problems. These discussions have led to successful outcomes, which include:

  • One hospital was able to increase timeliness of COVID-19 testing for their unit by describing what was done in other hospitals
  • Numerous hospitals used the webinar information to formulate their guidelines
  • Two hospitals secured PPE for their staff and physicians
  • Numerous maternal leaders were able to network and then consult with colleagues the following week on issues related to COVID-19
• Tip #29: Maternal Scope of Practice (Revisited)

  Tip

  Each facility should revisit their program plan and scope of care on a regular basis to ensure that their information is current, especially as it relates to the scope of services offered. The facility should also regularly monitor transfers, outcomes, and availability of personnel to ensure alignment with the written scope of practice. Any changes to the scope of practice should be communicated widely, and there should be documentation of staff education.

  Texas Rule

  §133.205(b) designation requirements for all levels (I to IV): "Program Plan. The facility shall develop a written plan of the maternal program that includes a detailed description of the scope of services available to all maternal patients, defines the maternal patient population evaluated and/or treated, transferred, or transported by the facility, that is consistent with accepted professional standards of practice for maternal care, and ensures the health and safety of patients."

  Scope of the Rule

  For all maternal designation levels, hospitals are required to have a program plan that delineates a detailed description of the scope of services including those patients who should be transported or transferred. In the plan, the facility should describe their maternal and neonatal services so that their medical and nursing staff are aware of which patients may be cared for at their facility and which should be transferred. This scope of maternal care should be communicated widely, and the services regularly updated. After the initial program plan and scope of care is delineated, many facilities don't revisit that document again until the next designation cycle. However, because circumstances change, the program plan and scope of care should be considered a living and constantly updated document.

  What factors affect the scope of care? 

  The personnel, health care providers, equipment, facility, teamwork, and communication are all important factors when determining a facility's scope of care. If there is a change to any component, the facility may not be able to care for that particular condition. For example, if the facility loses its neurosurgeon, the facility will not be able to handle maternal patients who require neurosurgical intervention, such as a pregnant patient with a moderate or large intracerebral aneurysm or a worrisome arteriovenous malformation. Pending recruitment of another neurosurgeon, maternal patients with neurosurgical conditions should be transferred, or the hospital should establish a delivery plan with another facility from the physician's office. This change in scope of care should be clearly communicated to hospital staff and nursing staff as well as any hospitals that may refer to the institution.

  How does the antenatal diagnosis affect the maternal scope of care? 

  Some maternal or neonatal conditions may be identified in the physician's office during a prenatal visit. Once identified, these patients can be referred to a higher-level facility to avoid transport or possible separation of the maternal patient and her infant. For example, if an antenatal diagnosis reveals a complex fetal congenital cardiac defect at a facility with a level II NICU, discussion with the facility's neonatal team, the higher-level facility, and maternal staff will allow for optimal counseling of the patient on the recommended delivery plan.

  How do quality reviews help determine the scope of care? 

  Hospitals should perform regular quality reviews to assess whether the documented maternal patients were triaged and transferred appropriately. Facilities should track the outcomes in patients with complex maternal conditions and compare those outcomes to regional, state, or national benchmarks. Outcome measures that deviate significantly from morbidity-adjusted benchmarks should alert the maternal medical director and maternal program manager to carefully investigate the reasons and take corrective action. Persistent poor outcomes that cannot be corrected should prompt deeper considerations, which may include outside consultation, root cause analysis, or temporary cessation of that particular service pending correction.

   
• Tip #30: Overseeing Interfacility Transports (Part 1)

  Tip

  The maternal medical director (MMD) or designee should review the interfacility maternal transports on a periodic basis, such as monthly, and document adverse events or near misses that occur during transport. The MMD or transport medical director (TMD) must conduct an in-depth review of these specific charts as soon as possible to safeguard patients and prevent other similar circumstances. If someone other than the MMD or TMD is designated to monitor transports, that person must notify the MMD and TMD regarding any problems on a timely basis to meet this rule. In addition, it is important that sending hospitals request information from the receiving facility about the patient outcome and feedback on improving the transport process. It is not sufficient to simply transfer the patient to another facility and assume everything went well.

  Texas Rule

  §133.205(d) stipulates that the responsibilities and authority of the MMD and/or TMD shall include: (d)(3) monitoring maternal patient care from transport if applicable, to admission, stabilization, operative intervention(s) if applicable, through discharge, and inclusive of the QAPI Program; and (d)(5) overseeing the inter-facility maternal transport.

  Scope of the Rule

  For all maternal designation levels, the MMD or TMD is responsible for overseeing the interfacility maternal transports, which includes transports in or out of the primary facility, and monitoring patient care from transport through discharge. The oversight is inclusive of QAPI.

  Frequently Asked Questions

  What should the MMD monitor regarding these transports?

  The MMD could consider reviewing both aggregate information and specific, problematic events during QAPI meetings. The QAPI meetings may have a standing agenda item of “interfacility transports from prior month” in which meeting participants review an aggregate report of transports. These reports may include number of patients transported in or out of the facility, number of term and preterm deliveries, indications, acuity level, reason for transport, and maternal and neonatal outcomes. The MMD or TMD should also ensure that there is an in-depth review of adverse events or near misses that occurred during transport.

  How should this oversight be documented?

  This process is best documented under QAPI so that the data can help drive quality improvement and monitoring and is protected under the quality committee. The quality committee should then educate staff and physicians, improve policies and guidelines, and monitor changes for compliance. 

• Tip #31: Overseeing Interfacility Transports (Part 2)

  Tip

  Improve your interfacility transport process by meeting with the hospitals that transport patients to your hospital and those that your hospital sends patients to. Consider holding joint QAPI meetings with the maternal leadership to review the interfacility maternal transports on a periodic basis, such as every two months or quarterly. Doing so can improve processes at the facilities and provide valuable information to the transport team. Hospitals should document these meetings in the QAPI minutes.

  Texas Rule

  §133.205(d) stipulates that the responsibilities and authority of the maternal medical director (MMD) and/or transport medical director (TMD) shall include: (d)(3) monitoring maternal patient care from transport if applicable, to admission, stabilization, operative intervention(s) if applicable, through discharge, and inclusive of the QAPI Program; and (d)(5) overseeing the inter-facility maternal transport.

  Scope of the Rule

  For all maternal designation levels, the MMD or TMD is responsible for overseeing the interfacility maternal transports, which includes transports into or out of the primary facility, and monitoring patient care from transport through discharge. The oversight is inclusive of QAPI.

  Frequently Asked Questions

  How do joint QAPI meetings help both the sending and receiving facilities? 

  Both the sending and receiving hospitals can provide feedback on patients transfers during joint QAPI meetings. For example, the receiving hospital can offer comments on whether the patient was sufficiently stabilized prior to transport and adequacy of the medical record, medication, and nursing documentation. The sending hospital can provide feedback on whether there was timely consultation, communication, and response to the request for transfer. This discussion helps both hospitals and the transport teams to improve their processes and identify opportunities for improvement and education.

  How can hospitals conduct productive joint QAPI sessions? 

  Improving patient care requires collaboration. During QAPI meetings, hospitals may be concerned that feedback will be interpreted as criticism and have negative consequences on transfers. By using maternal designation as an overarching structure, both facilities can set up an initial meeting to decide format, frequency, ability for both hospitals to provide equal feedback, mutual respect, and a safe place for open discussion. Some hospitals have found that alternating who leads the meetings is helpful.

• Tip #32: Ensuring the Availability of a Nutritionist or Dietician for Maternal Conditions (Part 1)

  Tip

  Ensure that patient’s dietary and nutritional needs are met by having the appropriate dietician or nutritionist services available in your hospital.

  Texas Rule

  • Level I [§133.206 (c)(17)] and Level II [§133.207 (c)(20)]: “dietician or nutritionist available with appropriate training and experience for population served in compliance with the requirements in §133.41 of this title.”
  • Level III [§133.208 (d)(28)] adds the following requirement: “Dietician or nutritionist available with training and experience in maternal nutrition and can plan diets that meet the needs of the pregnant and postpartum patient shall comply with the requirements in §133.41 of this title.”
  • Level IV [§133.209 (d)(27)]: further adds the following requirement: “Dietician or nutritionist available with training and experience in maternal nutrition and can plan diets that meet the needs of the pregnant and postpartum patient and critically ill maternal patient shall comply with the requirements in §133.41 of this title.”

  Scope of the Rule

  For all maternal designation levels, there is a need for a dietician or nutritionist available for the various populations served in the hospital. The consultation needs to be appropriate for the scope of patients, the complexity of the medical problems, and the caloric and nutritional needs of the patient.

  Frequently Asked Questions

  For a level I or II facility, what does the term “for population served” mean?

  The facility should perform an analysis of the type of patients that they serve and define those who would benefit from nutritional or dietician consultation. For example, these patients may include pregnant women with weight loss or inadequate weight gain, hyperemesis gravidarum, diabetes with poor control, or newly diagnosed diabetes including gestational diabetes. The key is that the conditions should be defined, staff and providers educated, the consult documented, and chart audits performed to ensure this consult is being done.

  For a level I or II facility, what does the term “appropriate training and experience” mean for a dietician or nutritionist?

  The consultant must have sufficient training or experience to apply the knowledge to the pregnant or postpartum patient. Because the maternal patient has unique physiological changes and conditions, the consultant must have sufficient education, training, and experience to render an appropriate assessment and recommendation. Please note: The next tip will address training and experience required in level III and IV facilities.

  Does the nutritionist or dietician need a special certification in maternal nutrition? 

  No. Although it is certainly exceptional to have a special certification in maternal nutrition, it is not necessary. However, nutritionists and dieticians must have current and continued education on nutritional or dietary assessment and care of the maternal patient.

   
• Tip #33: Ensuring the Availability of a Nutritionist or Dietician for Maternal Conditions (Part 2)

  Tip

  Ensure that patients’ dietary and nutritional needs are met by having the appropriate dietician or nutritionist services available in your hospital. This tip focuses on level III and level IV facilities.

  Texas Rule

  • Level I [§133.206 (c)(17)] and Level II [§133.207 (c)(20)]: “dietician or nutritionist available with appropriate training and experience for population served in compliance with the requirements in §133.41 of this title.”
  • Level III [§133.208 (d)(28)] adds the following requirement: “Dietician or nutritionist available with training and experience in maternal nutrition and can plan diets that meet the needs of the pregnant and postpartum patient shall comply with the requirements in §133.41 of this title.”
  • Level IV [§133.209 (d)(27)]: further adds the following requirement: “Dietician or nutritionist available with training and experience in maternal nutrition and can plan diets that meet the needs of the pregnant and postpartum patient and critically ill maternal patient shall comply with the requirements in §133.41 of this title.”

  Scope of the Rule

  For all maternal designation levels, there is a need for a dietician or nutritionist available for the various populations served in the hospital. The consultation needs to be appropriate for the scope of patients, the complexity of the medical problems, and the caloric and nutritional needs of the patient. Level III and IV facilities will have maternal patients with more complex medical conditions such as renal disease, liver disease, intestinal malabsorption problems, or difficult to control diabetes.

  Frequently Asked Questions

  For a level III and IV facility, what does the phrase “for population served” mean?

  The facility should perform a long-term study of the types of patients that they serve and define those who would benefit from nutritionist or dietician consultation. A limited review for a time period of only 12 months, for example, would likely not be sufficient, since many conditions are rare; thus, looking for five or more years to assess for those conditions where a nutritionist or dietician consultation would be warranted would assist the physician staff, nursing staff, and consultant staff. For example, these patients may include pregnant people with liver insufficiency, renal insufficiency, intestinal conditions including bypass surgeries, and brittle or difficult to control diabetes. Defining these conditions helps the nutritionist or dietician to be sufficiently current with knowledge and prompts the staff to schedule a consult. The key is that the conditions should be defined, staff and providers educated, the consult documented, and chart audits performed to ensure this consult is being done.

  For a level III or IV facility, what does the term “appropriate training and experience” mean for a dietician or nutritionist?

  The consultant must have sufficient training or experience to apply their knowledge to the pregnant or postpartum patient relative to the complex or critical conditions that are anticipated. These may include parenteral or enteral nutrition for maternal patients with severe hyperemesis gravidarum or chronic pancreatitis, malnutrition or vitamin deficiencies, or metabolic disorders including complex diabetes. It could also include maternal patients requiring special diets for their own health or that of their infant, for conditions such as phenylketonuria. Because the maternal patient has unique physiological changes and conditions, the consultant must have sufficient education, training, and experience to render an appropriate assessment and recommendation.

  Does the nutritionist or dietician need a special certification in maternal nutrition?

  No. Although it is certainly exceptional to have a special certification in maternal nutrition, it is not necessary. However, nutritionists and dieticians must have current and continued education on nutritional or dietary assessment and care of the maternal patient. For level III and IV facilities, these consultants should have evidence of current education for the complex conditions relative to maternal patients.

   
• Tip #34: Enforcing Policy (Part 1)

  Tip

  It is a critical responsibility of every facility to enforce program policies and procedures. Often times, facilities dedicate time and effort to write a comprehensive program plan and update policies and procedures that govern the clinical care of patients. However, this is just the first step. The hospital staff and medical staff (health care professionals) must be aware of the existing policies and any modifications to these policies and educated about new ones. There must be monitoring to ensure that policies are implemented and followed.

  Texas Rule

  §133.205 (b) Program Plan. (1) The written plan and the program policies and procedures shall be reviewed and approved by the facility's governing body. The governing body shall ensure that the requirements of this section are implemented and enforced. (2) The written maternal program plan shall include, at a minimum: (A) Program policies and procedures that are: (i) based upon current standards of maternal practice; and (ii) adopted, implemented and enforced for the maternal services it provides.

  Scope of the Rule

  This rule is relevant for all facilities from level I to level IV. It is considered a high priority, since it is assumed that the hospital has developed policies and procedures that are current, relevant, and important to guide the safety and care of patients. Facilities should review the policies and procedures frequently to ensure that they reflect current standards and are relevant to current practice. The health care team should be educated on and reminded frequently of the key parts of policies or procedures. Active monitoring for compliance with policies and procedures is important, with results of monitoring documented in QAPI. Policies or procedures should be changed if parts are outdated or not relevant. In addition, maternal staff should receive education and reinforcement of policy changes through educational activities and active team-based drill participation.

  Frequently Asked Questions

  How will the survey team determine whether our hospital is enforcing our policies and procedures?

  The main way to assess whether a facility is enforcing its policies and procedures is through the chart review. During the chart audit, the surveyor will examine each chart to evaluate if there is consistency with current community standard, whether the policy or procedure is evidence-based, and if policies and procedures were followed in the care of the patient.

  If our hospital has just finished updating our policies and procedures, will the charts be held to the new policies?

  In general, the answer is yes, surveyors will evaluate care of the patient based on current policies and procedures, even if the charts reflect care before the current policy was in place. The degree of the adverse event or potential adverse event plays a role; for example, a simple documentation issue is not as significant as nonadherence to a critical intervention, such as notifying a physician of severe hypotension. For this reason, it is important to develop current policies and procedures at least 12 months prior to the site visit to ensure that patient care reflects the current standards.

  What happens if our charts don’t comply with an area of the policy that is inadvertently stricter than community standard? For example, if we ask for deep tendon reflexes every 15 minutes on magnesium sulfate versus the community standard of every hour.

  The surveyors will use the hospital’s own policies and procedures to guide whether the practice is adherent to its own policies. In the case of the example given, if the nurses assess every one hour instead of every 15 minutes, the surveyors will conclude that the facility is “not enforcing its policy and procedures.” For this reason, it is important to carefully review each policy and procedure and cross-reference with the community standard.

   
• Tip #35: Enforcing Policy (Part 2)

  Tip

  It is a critical responsibility of every facility to enforce program policies and procedures. Oftentimes, facilities dedicate time and effort to write a comprehensive program plan and update policies and procedures that govern the clinical care of patients. However, facilities must actively monitor employees to ensure compliance with policies and prioritization of those interventions that have the most significant effect on patient safety and well-being. Maternal leadership should explain the rationale for the various aspects of the policies to the hospital staff and medical staff or health care professionals so that they can successfully implement the practices. 

  Texas Rule

  §133.205 (b) Program Plan. (1) The written plan and the program policies and procedures shall be reviewed and approved by the facility's governing body. The governing body shall ensure that the requirements of this section are implemented and enforced. (2) The written maternal program plan shall include, at a minimum: (A) Program policies and procedures that are: (i) based upon current standards of maternal practice; and (ii) adopted, implemented and enforced for the maternal services it provides.

  Scope of the Rule

  This rule is relevant for all facilities from level I to level IV. It is considered a high priority, since it is assumed that the hospital has developed policies and procedures that are current, relevant, and important to guide the safety and care of patients. Maternal leaders should review policies or protocols with staff and health care professionals on a regular basis and ask if guidelines are reasonable and if policies are being followed. This practice can help identify or prevent a work-around if the protocol is viewed as inefficient. Leadership should create a culture in which hospital staff or health care professionals feel the freedom to report potential noncompliance in a blameless and nonpunitive manner.

  Frequently Asked Questions

  Can chart audits help assure compliance with policies?

  Yes, auditing charts for those priority areas that affect patient care or safety can be helpful. In addition to these priority areas, the reviewer should also consider other areas of documentation or noncompliance unrelated to the reason for the chart audit. Once the reviewer identifies an area of noncompliance, a wider study should be undertaken to determine its prevalence. More intensive interventions (eg, education, monitoring) are required for areas of greater clinical significance and more frequent in occurrence.

  How do maternal leaders ensure that policies continue to be followed?

  One important area is to address any communication disconnects between maternal leadership and hospital staff and health care professionals. These gaps are common in nearly all hospital settings. When the leadership identifies a system issue and enacts a policy change, it is important that hospital staff and health care professionals receive education on the change and understand it. In the short term, members of the team are usually keenly aware of and comply with the new rule. However, with time, hospital staff and health care professionals may slip back into noncompliance due to new staff or laxity. Maternal leadership can consistently review policies or protocols with staff and providers, discuss the reasons for the policies, and identify barriers to policy implementation. Continue to monitor for compliance (initially frequently, and then less often, but still with some regularity).