| (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.
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