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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 133HOSPITAL LICENSING
SUBCHAPTER KHOSPITAL LEVEL OF CARE DESIGNATIONS FOR MATERNAL CARE
RULE §133.205Program Requirements

(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.

(b) 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.

  (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;

    (B) a periodic review and revision schedule for all maternal care policies and procedures;

    (C) written triage, stabilization, and transfer guidelines for pregnant and postpartum patients that include consultation and transport services;

    (D) written guidelines or protocols for prevention, early identification, early diagnosis, and therapy for conditions that place the pregnant or postpartum patient at risk for morbidity and/or mortality;

    (E) provisions for unit specific disaster response to include evacuation of maternal patients and infants to appropriate levels of care;

    (F) 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;

    (G) requirements for minimal credentials for all staff participating in the care of maternal patients;

    (H) provisions for providing continuing staff education, including annual competency and skills assessment that is appropriate for the patient population served;

    (I) a perinatal staff registered nurse as a representative on the nurse staffing committee under §133.41 of this title; and

    (J) the availability of all necessary equipment and services to provide the appropriate level of care and support of the patient population served.

(c) Medical Staff. The facility shall have an organized maternal program that is recognized by the medical staff and approved by the facility's governing body.

  (1) The credentialing of the maternal medical staff shall include a process for the delineation of privileges for maternal care.

  (2) The maternal medical staff will participate in ongoing staff and team based education and training in the care of the maternal patient.

(d) Medical Director. There shall be an identified Maternal Medical Director (MMD) and/or Transport Medical Director (TMD) as appropriate, responsible for the provision of maternal care services and credentialed by the facility for the treatment of maternal patients. The responsibilities and authority of the MMD and/or TMD shall include:

  (1) examining qualifications of medical staff requesting maternal privileges and making recommendations to the appropriate committee for such privileges;

  (2) assuring maternal medical staff competency in managing obstetrical emergencies, complications and resuscitation techniques;

  (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;

  (4) participating in ongoing maternal staff and team based education and training in the care of the maternal patient;

  (5) overseeing the inter-facility maternal transport;

  (6) 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;

  (7) frequently leading and participating in the maternal QAPI meetings;

  (8) ensuring that the QAPI Program is specific to maternal and fetal care, is ongoing, data driven and outcome based;

  (9) participating as a clinically active and practicing physician in maternal care at the facility where medical director services are provided;

  (10) maintaining active staff privileges as defined in the facility's medical

staff bylaws; and

  (11) developing collaborative relationships with other MMD(s) of designated facilities within the applicable Perinatal Care Region.

(e) Maternal Program Manager (MPM). The MPM responsible for the provision of maternal care services shall be identified by the facility and:

  (1) be a registered nurse with perinatal experience;

  (2) be a clinically active and practicing registered nurse participating in maternal care at the facility where program manager services are provided;

  (3) has the authority and responsibility to monitor the provision of maternal patient care services from admission, stabilization, operative intervention(s) if applicable, through discharge, and inclusive of the QAPI Program;

  (4) 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;

  (5) frequently leads and participates in the maternal QAPI meetings;

  (6) ensures that the QAPI Program is specific to maternal and fetal care, is ongoing, data driven and outcome based; and

  (7) develops collaborative relationships with other MPM(s) of designated facilities within the applicable Perinatal Care Region.


Source Note: The provisions of this §133.205 adopted to be effective March 1, 2018, 43 TexReg 875

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