OB Services
Organization and Staffing
The Centers for Medicare and Medicaid Services (CMS) would require under the proposed rule that hospitals and critical access hospitals (CAHs) providing OB services outside of an emergency department “must be well organized and provided in accordance with nationally recognized acceptable standards of practice for the health care (including physical and behavioral health) of pregnant, birthing, and postpartum patients.” CMS is also proposing that the organization of the OB services be appropriate to the scope of services offered by the facility and be integrated with other departments in the facility. For example, in order to provide high-quality and safe care, a labor and delivery (L&D) unit must ensure good communication and collaboration with services such as laboratory, surgical and anesthesia services when applicable. Additionally, the proposed rule requires OB units to be supervised by an individual with necessary education and training, such as an experienced registered nurse (RN), certified midwife, nurse practitioner, physician assistant, or doctor of medicine or osteopathy. Lastly, CMS is proposing that OB privileges be delineated for all practitioners providing OB care, and a roster of practitioners specifying the privileges of each practitioner must be maintained.
Delivery of Service
CMS is proposing a new standard that requires OB services to be consistent with the needs and resources of the facility. Additionally, the policies governing OB care must assure high standards of medical practice and patient care and safety. The proposed rule would mandate that L&D rooms have certain basic resuscitation equipment readily available, including a call-in system, cardiac monitor and fetal doppler or monitor. Lastly, CMS is proposing that the facility ensure that it has adequate, readily available provisions and protocols consistent with nationally recognized and evidence-based guidelines for OB emergencies, complications, immediate post-delivery care and other patient health and safety events. Examples of provisions would include equipment, supplies and blood used in treating emergency cases.
Staff Training
CMS is proposing a new standard that requires hospitals and CAHs that offer OB services outside of the emergency department to develop policies and procedures to ensure that relevant staff are trained on certain topics aimed at improving the delivery of maternal care. These training topics must reflect the scope and complexity of services offered, including facility-identified evidence-based best practices and protocols to improve the delivery of maternal care within the facility.
Additionally, CMS is proposing that hospitals and CAHs use findings from their QAPI programs (see below) to inform staff training needs and any additions, revisions, or updates to training topics on an ongoing basis. Lastly, the proposed rule requires that the hospitals and CAHs providing OB services (a) identify which staff must complete the trainings, (b) document in staff personnel records that training was successfully completed, and (c) be able to demonstrate staff knowledge on the training topics identified.
QAPI Program
The proposed rule revises the existing Quality Assessment and Performance Improvement (QAPI) Program CoP for hospitals and CAHs that offer OB services to promote safe and high-quality care for all pregnant, birthing and postpartum patients. Hospitals or CAHs with OB services would be required to use their own QAPI program to assess and improve health outcomes and disparities among OB patients on an ongoing basis. At a minimum, the facility would have to:
- Analyze data and quality indicators collected for the QAPI program by diverse subpopulations as identified by the facility among OB patients;
- Measure, analyze, and track data, measures, and quality indicators on patient outcomes and disparities in processes of care, services and operations, and outcomes among obstetrical patients;
- Analyze and prioritize patient health outcomes and disparities, develop and implement actions to improve patient health outcomes and disparities, measure results, and track performance to ensure improvements are sustained when disparities exist among obstetrical patients; and
- Conduct at least one performance improvement project focused on improving health outcomes and disparities among the hospital’s population(s) of obstetrical patients annually.
Additionally, the proposed rule would require that each OB facility’s leadership be involved in the facility’s QAPI activities. Per existing state statutes, facilities are already required to report data to maternal mortality review committee/s (MMRC/s). Therefore, CMS is proposing that if a MMRC is available at the state or local jurisdiction in which the facility is located, hospitals and CAHs that offer OB services must have a process for incorporating information and data from the MMRC into the hospital QAPI program.
Emergency Services
The proposed rule revises the Emergency Services CoP to improve facility readiness in caring for emergency services patients, including pregnant, birthing and postpartum women. These proposed emergency services requirements would apply to all hospitals and CAHs offering emergency services, regardless of whether they provide specialty services, such as OB services. Hospitals and CAHs with emergency services be required to have adequate provisions and protocols to meet the emergency needs of patients that are consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions. Applicable staff would need to be trained in these protocols and provisions annually, and documentation would be expected to show those staff members who have successfully completed such facility-identified training.
Hospitals must have provisions that include equipment, supplies and medication used in treating emergency cases. The available provisions must include the following:
- Drugs, blood and blood products, and biologicals commonly used in lifesaving procedures;
- Equipment and supplies commonly used in lifesaving procedures;
- A call-in system for each patient in each emergency services treatment area.
Transfer Protocols
As part of the new CoPs, the proposed rule would require hospitals to have written policies and procedures for transferring patients to the appropriate level of care needed to meet the patients’ needs. This would include the internal transfer of hospital inpatients (e.g., transfer of patient from one unit to another unit within the same hospital). This would also include transferring the patient to another hospital if deemed necessary. Lastly, the rule proposes that hospitals provide training to the relevant staff regarding the hospital policies and procedures for transferring patients.