Tier 1 Requirements. First Arm - Year One: Successful completion of

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1 Thank you for participating in the BETA Healthcare Group Quest for Zero: OB Risk Management Initiative. We will make every effort to assure that the assessment goes as efficiently and expeditiously as possible for you. Outlined below are the elements of our initiative and the associated documents that will be needed to validate that the requirements have been met. Section 1 describes the indicator requirement as well as the associated documents that are requested for review to meet Tier 1 of the OB initiative. Note: To be eligible for Tier 2, Tier 1 requirements must be met. Section 2 describes the indicator requirements and associated documents that are requested for review to meet the Tier 2 requirements. Please review both sections carefully and kindly forward any policies that are listed for review to the undersigned prior to the visit. The remaining records shall be made available for review on the date of the scheduled validation. Tier 1 Requirements Indicator Document Request Standardized Nomenclature L&D policy and procedure manual Access to electronic medical record if in place in OB OB privilege sheet outlining the requirement to comply with NICHD terminology in the OB setting 10 randomly selected patient records with fetal monitor tracings First Arm - Year One: Successful completion of an AWHONN/ACOG endorsed electronic fetal monitoring class that includes standardized nomenclature (NICHD) within 3 months of appointment and/or date of hire for all providers who practice in the L&D setting Second Arm Year Two & Three: Successful completion of 7 modules of APS courseware Competency Maintenance. Once 7 modules are completed they may not be repeated. List of all providers who deliver babies in L&D List of all registered nursing staff who participate in the delivery process Job description or Human Resources policy outlining requirements of for hire of L&D nurse Certificates of coursework completion (APS/AWHONN/ALSO) of all providers and staff

2 Tier 2 Requirements Fetal Strip Review Document Request Multidisciplinary* electronic fetal monitoring Logs or strip review sign-in sheets to (EFM) strip reviews are attended, at minimum, confirm documentation of participation six times per year by all providers and nursing Will reference staff lists as requested staff who care for laboring mothers above *Participants must include an OB physician, Family Practitioners who deliver babies, L&D unit nurses, residents and CNM s. Simulation and Drills In a multidisciplinary fashion, high or low fidelity simulation (in-situ or offsite) or drills are conducted twice per year Two high-risk, low frequency issues will be pre-selected based on organization s trends or national trends This criterion requires evidence of a debrief process Culture of Safety Unit specific information is gathered through a survey process specifically targeting culture and teamwork behaviors in the Perinatal setting At minimum, four lessons from losses or case study presentations are shared with staff specific to medical error or near miss activity. Department specific event trends are shared quarterly at medical staff and nurse staff meetings Evidence of staff participation through sign-in sheets Evaluation and planning form which describes identified disciplines Evidence of evaluation of high-risk, low frequency events that were selected Debrief summary of each simulation/drill scenario Culture survey baseline survey results Case study or PPT presentations of Lessons from Losses shared Sign-in sheets for attendance in those sessions Evidence of event trend information shared at staff meetings on a quarterly basis through review of staff meeting minutes Evidence of frequency of WalkRounds, information obtained and evidence of feedback Leadership WalkRounds are implemented by December 1 of the policy period and are conducted at least monthly. Information is obtained, recorded, and there is a feedback mechanism in place.

3 Communication Deliver Crucial Conversations training to all staff that practice in the Perinatal Services area Implement a unit specific chain of command policy Implement SBAR-R tool. Utilize in verbal report Track and monitor effectiveness of the adoption of SBAR-R with evidence of observation for compliance Elective Induction Bundle Implement bundle requirements and measure for compliance. 90% compliance must be achieved by May 1 of the policy period Vacuum Bundle Implement bundle requirements and measure for compliance. 90% compliance must be achieved by May 1 of the policy period Evidence of participation through sign-in sheets Chain of Command Policy 10 patient records randomly selected to demonstrate evidence of use of SBAR tool Data set which demonstrates evidence of observations conducted and measures of success Evidence of quality indicator measured by quality department statistics Policy Review: o Induction of Labor o Cervical Ripening o Electronic Fetal Monitoring Tachysystole algorithm with evidence of medical staff approval (Committee minutes or documentation thereof) 10 patient records admitted for elective delivery Evidence of quality indicator measured by quality department statistics Quality data showing volume of vacuum delivery Evidence of quality review of 100% vacuum assisted delivery Evidence of education to staff on Operative Vaginal Delivery (Certificates of completion of APS coursework or other) Policy Review: o Vacuum Assisted Delivery or Operative Vaginal Delivery 10 patient records that demonstrate they underwent vacuum assisted delivery

4 Obstetrical Hemorrhage All staff in L&D, antepartum and postpartum must complete the postpartum hemorrhage module offered through APS or other coursework offered through CMQCC s project on OB hemorrhage A hemorrhage protocol is in place Simulation and/or drills specific to OB hemorrhage occur annually Evidence of certificates of completion of APS module Postpartum Hemorrhage OB Hemorrhage Policy/Protocol and evidence of approval Evidence of participation of all staff involved in an OB hemorrhage such as sign-in sheets Quality metrics demonstrating blood utilization review An OB hemorrhage cart is in place in L&D and postpartum Blood utilization is reviewed as a quality metric Shoulder Dystocia A risk screening/stratification methodology is in place and has undergone approval by medical staff A second stage of management protocol is in place and approved by medical staff Interventions employed during shoulder dystocia are evidenced in charting Screening tool Policy Review o Shoulder dystocia 10 patient records of those who experienced a shoulder dystocia Evidence of participation by all involved providers and staff in simulation/drill as demonstrated by sign-in sheet Simulation and/or drills specific to shoulder dystocia occur, at minimum, annually and there is evidence of participation by all involved staff NCC Certified Staff Indicator All eligible staff in the departments listed below will sit for the RNC exam Inpatient Obstetrical Nursing Neonatal Intensive Care Nursing Low Risk Neonatal Nursing Maternal Newborn Nursing Listing of all employed staff to include dates of hire Verification of certification of all staff who meet eligibility requirements

5 Perinatal Medication Safety All staff have viewed the ISMP perinatal medication safety DVD All structure standards have been met for safe use of five common medications that are administered in Perinatal Services Oxytocin Magnesium Sulfate Misoprostol/Cytotec Heparin (in NICU) Epidural analgesia Hyperbilirubinemia Baby Friendly status achieved and acknowledged by the World Health Organization and UNICEF 39 week criteria is in place and meeting The Joint Commission core measure set at minimum of 90% compliance over a 12 month period A policy is in place for nurse initiated TcB or TsB via protocol Staff sign-in sheet demonstrating that the video was viewed Policy Review o Cervical Ripening o Induction of Labor o VBAC o Electronic Fetal Monitoring o Postpartum Hemorrhage o Epidural analgesia o High alert medication o Heparin o Magnesium Sulfate and/or Pregnancy Induced Hypertension and Preterm Labor Interview with pharmacy staff and observation of practice Tachysystole algorithm with evidence demonstrating approval by medical staff Evidence of annual drill focused on OB hemorrhage Sign-in sheet demonstrating evidence of attendance Evidence of certification Quality metrics illustrating compliance Policy or protocol addressing jaundice of the newborn Sample 10 charts for evidence of discharge instructions demonstrating understanding by the patient and advice for follow-up Discharge instruction includes information to patients pertaining to symptoms of jaundice in the newborn

6 Second Stage of Labor Management A policy is in place pertaining to second stage of labor management and incorporates the AWHONN second stage of labor management algorithm A Performance Improvement measure is in place which evaluates the following criteria: o Management according to algorithm o Fetal evaluation and timely intervention of Category III tracing o Sample size 10/month Policy review 10 randomly selected medical records of delivered patients in last 6 months demonstrating 100% compliance Policy review A policy is in place which requires cord gas analysis for established indications and retention policy of 7 days A policy is in place which requires placental pathology for established indications o The policy shall allow for the neonatologist to order pathological exam should an indication be overlooked Patient and Family Centered Care The BETA member hospital has completed a readiness assessment as it pertains to the philosophy of the organization to adopt and a patient and family centered care approach A policy and structure is in place that includes patients on teams in the perinatal area EMMI Solutions is fully adopted by the OB department as evidenced by 90% of eligible patients where programs were assigned/delivered Evidence of completed readiness assessment The risk management plan or patient safety plan define this structure and participation is evident in meeting minutes Volume statistics and EMMI usage report Patient satisfaction metrics illustrating performance in the 90 th percentile in OB services The facility measures patient satisfaction and has achieved the 90 th percentile at minimum over the last 6 months

7 Preeclampsia BETA member hospital is enrolled and is an active participant in the CMQCC Preeclampsia Collaborative Evidence of project work is demonstrated with metrics outlined as Performance Improvement project and aligned with the Collaborative metrics Evidence of participation Performance improvement metrics Provide evidence of education and participation of all providers and nurses Policy specific to preeclampsia and the management of preeclampsia Evidence of education is provided to all staff who care for the preeclamptic patient to include postpartum staff A policy is in place addressing the care of women with preeclampsia in accordance with ACOG Practice Bulletin Thank you again for your ongoing commitment to patient safety in the perinatal setting. I look forward to celebrating your team s success. Sincerely, Heather Gocke, B.S., RNC-OB, LNC, CPHRM, C-EFM Director of Risk Management/Patient Safety BETA Healthcare Group hgocke@betahg.com