April 28, 2015 Overview to Perinatal Care Certification Webinar Question and Answer Session

Transcription

1 Webinar Question Are there different requirements/expectations depending on an institution/organizations ACOG/AAP Level of care status, i.e. 1,2,3,4? What is the approximate cost to the facility and is this a yearly certification/recert process? Do we need PI projects and data measures other than the core measures to report on a monthly basis? Webinar Response The certification requirements apply to those certified regardless of level of care. We require the program to provide care, treatment and services to meet the needs of the population they serve based on the scope of services offered (PNPM.3, EPs 1-13) and we require the program to identify and manage mothers and/or newborns who should be transferred to another setting that provides care outside the scope of the organization's level of care but we specify the minimum capabilities the program should have in place to manage such high-risk patients for transfer (PNPC.5, EP11); and the minimum processes they must have in place for transfer to an appropriate level of care (PNPC.5, EP12). The cost varies dependent on the number of certification programs the customer has with The Joint Commission. All customers should call the Business Development department at (630) for their individual cost. The certification period is for two years. The performance measure requirements for Perinatal Care Certification are data collection for the PC core measures with quarterly submission of monthly data points to The Joint Commission. Data collection for other performance measures is not required; however, programs must also meet the Perinatal care standard requirements for performance measurement (PNPI) to achieve and maintain certification status. In addition to the PC core measures please refer to the PNPI chapter of the Perinatal Care standards for additional PI data programs should be collecting.

2 PNPM Who are considered the leaders in this standard? Just the perinatal care coordinator or the hospitals leadership? Are there more than one surveyor in this onsite process? Is the application process only available annually? April 28, 2015 The PNPM.2 standard states that the program defines its leadership. PNPM.2, EP1 states that the program has leadership and staff necessary to meet the scope of care, treatment, and services it provides across the continuum of care. PNPM.2, EP2 states that the program has a designated leader who is accountable for the perinatal care program. This leader provides: integrated, coordinated, patient-centered care that starts with prenatal care and continues through postpartum care, provides early identification of high-risk pregnancies and births and manages mothers' and newborns' risks at a level that corresponds to the program's capabilities, direct care or stabilizes and safely transfers mothers and/or newborns who require care beyond the scope of services provided by the organization, for identified or unanticipated high-risk pregnancies and births or maternal, fetal, and newborn problems, patient education and information about perinatal care services available to meet mothers' and newborns' needs so that mothers can make informed decisions about their care, and has ongoing quality improvement processes for making improvements to the program from prenatal to postpartum care. PNPM.2, EP3 requires a qualified provider with obstetric privileges to be responsible for management of the program's obstetric services. PNPM.2, EP4 requires a qualified provider with pediatric privileges to be responsible for management of the program's newborn unit services. PNPM.2, EP5, requires a qualified provider with anesthesia privileges to be responsible for management of the program's obstetric anesthesia services. PNPM.2, EP6, requires a nursing leader with perinatal nursing care experience to be responsible for management of the program's perinatal nursing care services. PNPM.2, EP7, requires that the programs perinatal leaders define both the shared and unique responsibilities and accountabilities of its leadership and staff. PNPM.2, EP8 requires program leaders to share best practices with other leaders of perinatal programs. PNPM.2, EP10, requires the program leader to make certain that practitioners practice within the scope of their licensure, certification, training, and current competency There will be one or two reviewers based on the scope of the program Organizations can apply at any time after July 1, 2015

3 Is certification optional or mandatory? Is there additional information available regarding the interdisciplinary care planning process? Is there a minimum number of patients required to be included or is this solely risk-based? The Perinatal Certification program is optional. Need clarification regarding question 1. Per the Perinatal Care Certification general eligibility requirements, the program must have served a minimum of 10 patients at the time of their review. You mentioned that certain services are required to be 24/7. If our facility does not have 24/7 anesthesia would we qualify for certification? The program must provide anesthesia services 24/7 and must have suitable backup systems and plans in place to meet the needs of the mother/newborn (see PNPM.3, EP 5; PNPM.7, EP 4). The program must have a qualified anesthesia services provider immediately available, defined as "a resource that is available on site as soon as it is requested and is based on each program's available resources and geographic location" (see PNPM.7, EP 1). The medical record contains sufficient information Referring to PNIM.2, EP 1 the medical record is speaking of both the mother's and to identify the mother and newborn. Does this newborn's medical records which should include information sufficient to identify the mean that the baby can be identified from the mother and newborn. Refers to both of their records (See PNIM.2,EPs 1-6). mother's chart and vice versa or are you asking that the patient can be identified? How long would the certification be good for? What is the benchmark you are looking for around exclusive breastfeeding? Do you anticipate having QI benchmarks as part of this program? The Perinatal Care Certification is a two year certification The Joint Commission does not set benchmarks for any of the certification performance measures. You are expected to monitor your progress from quarter to quarter for trends. Benchmarks have not been established for the certification performance measures. Organizations may track their individual performance via the CMIP trend reports. Aggregate measure rates for the PC measures are available on Quality Check and detailed in The Joint Commission Annual Report. Yes. The on-site review fee is covered in the certification cost. What is the cost of this certification and is the site visit included? How long does the certification last? The Perinatal Certification program is on a two year cycle. How long is a typical survey process? The review process is two days long.

4 It is very plainly evident in the literature that continuous EFM is associated with increased cesarean sections, and operative vaginal deliveries. It is commendable that The Joint Commission is examining practices and perinatal care to decrease cesareans, and so affect maternal mortality. To that end, let s not ignore this important variable. The United States preventative services task force, since 1996, has clearly stated that EFM is merely a screening tool, and is not to be used universally for obstetric patients. It is to be reserved for those who meet risk criteria. Universal and unwarranted use of continuous EFM also is a violation of informed consent and patient autonomy. The data shows that applying the fetal monitor continuously increases the risk for C-section by 20%. Yet no patient is being told of this effect. Please tell me how we can enlist the support of The Joint Commission in stopping the overuse of continuous EFM and reinstating the evidencebased practice of intermittent auscultation? April 28, 2015 We engaged our Technical Advisory Panel and the field regarding fetal heart rate monitoring. Based on the feedback received, it was determined that a program should have the capability to provide intermittent auscultation and continuous fetal monitoring (see PNPM.3, EP 4; PNPM.6, EP 4). The capability of conducting continuous monitoring is so the program is capable of addressing unanticipated complications such as fetal heart rate abnormalities (see PNPC.5, EP 10). The method that is used depends on the mother's or fetus's risk assessment, the health care provider's clinical judgement, the program's policy and the mother's preference (see PNPM.3, EP4). I don't see anyone like International Lactation Consultant Association or Baby Friendly USA on your list of advisory groups. I'm curious about this lack. How many days is the actual survey going to be? The review process is two days long. We received feedback from the ILCA and Baby Friendly for the proposed requirements during the field review and also through conference call.

5 Does this survey include onsite visits to physician offices to remove prenatal and post natal information? And if Yes, would that only include offices under our CCN number? The on site process involves a discussion regarding interdisciplinary care and would include discussions regarding pre and post care. If already State Certified (Arizona Perinatal Trust) will that be recognized by The Joint Commission? What is the application process and the fee? For the ten patients that will be reviewed, is that from an individual unit (i.e. Mother baby unit) or is it within the perinatal unit? Is the Certification Participation Requirements (CPR) chapter available for review online? The Joint Commission does not accept state certifications in place of certification through The Joint Commission. States may choose to accept The Joint Commission certification in lieu of their state requirements. Healthcare organizations should contact their Account Executive when they are ready to apply for certification. If the healthcare organization has additional questions about the certification they should contact the Business Development Department. The tracers during the review will be within the Perinatal program. The Certification Participation Requirements (CPR) chapter is online at the present time and will be available to the organization upon application submission and deposit. Also, if the organization is interested in reviewing them prior to application submission they can work with the Joint Commission Business Development department to receive a free trial. Is this certification for Level III hospitals or for community hospital level? The certification requirements apply to those certified regardless of level of care. We require the program to provide care, treatment and services to meet the needs of the population they serve based on the scope of services offered (PNPM.3, EPs 1-13) and we require the program to identify and manage mothers and/or newborns who should be transferred to another setting that provides care outside the scope of the organization's level of care but we specify the minimum capabilities the program should have in place to manage such high-risk patients for transfer (PNPC.5, EP11); and the minimum processes they must have in place for transfer to an appropriate level of care (PNPC.5, EP12).

6 Are there required staffing (nurse/patient ratio) stipulations? We do not specify ratios. We require the program includes qualified labor, delivery, surgical, recovery, and neonatal nursing personnel in adequate numbers to meet the needs of each patient in accordance with the setting (see PNPM.7, EP 1). Do you have a gap analysis template to use as a guide to implement the program? I thought that we could not submit our application until July 1. Will the physician program director need a job description in their file? Is this certification pertinent to a Regional Perinatal Organization? Is this certification hospital specific or could all 4 of our hospitals in our system be surveyed all at one time? Will core measure compliance be a requirement for certification, or will having core measure achievement in PI process for a minimum of 4 months be sufficient? No. Applications will be accepted July 1, Currently this is not a requirement in the perinatal care standards. If the organization requires a job description for the physician program director, then the reviewer will expect to see a job description on file. Accountability is the focus for the Perinatal Care designated leader (see PNPM.1 and PNPM.2). Qualified leaders for services - please refer to the accreditation standards, including the Medical Staff chapter regarding privileging and credentialing. Yes. All certification and accreditation programs are site specific. We can schedule your on site reviews for your hospitals on consecutive days. The Joint Commission requirement (standard PI element of performance 1) for hospital accreditation that established compliance with an 85% composite target rate for performance on ORYX accountability measures does not apply to the certification decision. Organizations seeking initial Perinatal Care Certification must collect 4 months of data for each of the perinatal care measures prior to the initial certification visit and submit monthly data points for each measure on a quarterly basis to maintain certification status. Our delivery rate is 500 per year. Do we qualify? Yes. Per the Perinatal Certification general eligibility guidelines, the program must have served a minimum of 10 patients at the time of their review.

7 If the focus is on the uncomplicated cases, why is the antenatal steroid population for core measure being reviewed? How much historical data is requirement to submit the application and then for survey? If something falls out during your survey, are you provided with an opportunity to correct and resubmit for the certification? Has the Joint Commission established a goal for PC05A? Will it be required to obtain this perinatal care advanced certification program in order to then certify in high risk certification program now under development? April 28, 2015 The focus of the Perinatal Care Certification program is on uncomplicated cases; however, as well as insuring programs have the necessary resources or processes in place in the event of an unanticipated complication (see PNPC.5, EP 10). All core measures are part of this certification. If zero denominator = 0; the measures are considered a bundle. Organizations seeking initial Perinatal Care Certification must collect 4 months of data for each of the perinatal care measures prior to the initial certification visit and submit monthly data points for each measure on a quarterly basis to maintain certification status. Need more information. This measure will be retired effective with 10/1/15 discharges and will not be applicable to the Perinatal Care Certification program. The Joint Commission does not normally require one certification prior to achieving a second or more advanced certifications. There has not been a decision about this yet. Can you please clarify if the 24/7 anesthesia The program must provide anesthesia services 24/7 and must have suitable backup requirement means on-site 24/7 or available 24/7 -systems and plans in place to meet the needs of the mother/newborn (see PNPM.3, EP as outlined in the Guidelines for Perinatal Care? 5; PNPM.7, EP 4). The program must have a qualified anesthesia services provider immediately available, defined as "a resource that is available on site as soon as it is requested and is based on each program's available resources and geographic location" (see PNPM.7, EP 1).

8 We are from the State of Illinois, north of the Chicagoland area. We are currently required to be reviewed by the Illinois Department of Public Health along with our Perinatal Network Administration every three years. This outline almost mirrors what is required from us at that review. What is the advantage to obtaining this additional certification, and, will this ultimately be a required certification of the JC? Thank you. 1. How do you determine what is evidence based practice and guideline? 2. How does this program relate to the ACOG and SMFM levels of maternal care that were recently published? Currently there are no plans to make this a required certification. The Perinatal Care Certification can be an adjunct to your requirements from the Illinois Department of Health and Perinatal Network Administration. The certification is looking at the complete program from prenatal through L&D and the first postpartum visit and the communication between these settings. It requires a standard process of care, so that variation is decreased, mom and baby care is individualized based on their needs and improved outcomes are demonstrated. The certification program requires the Perinatal Care program to have processes in place to effectively manage emergencies when they arise. This program was designed prior to the ACOG SMFM 2015 joint consensus statement. However, it is important to note that we had both ACOG and SMFM representation on the TAP. PNPM.7 requires someone with obstetric privileges to be in the delivery area when a mother is in active labor. Clarify how that will be surveyed. What is your definition of active labor? When will the glossary be available? How many FTEs will it take to maintain this program? The obstetric provider should be present at the time of delivery. We do not define active labor, ACOG's definition is generally accepted in the field (see how the program defines active labor and that it is consistent). Would records indicate the mother's progression of labor and at what point the provider was available in the delivery room? (See PNPM.7, EP 1) The glossary is online at the present time and will be available to the organization upon application submission and deposit. Also, if the organization is interested in reviewing the glossary prior to application submission they can work with The Joint Commission Business Development department to receive a free trial. We do not have requirements associated with FTEs for the Perinatal Care Certification program. Please refer to PNPM.2 PNPM.7, EPs 1 and 2 for requirements related to leadership, interdisciplinary team and support service roles of the program.

9 When is the application submitted? When the intent is present or when we feel we are ready to pass certification? The healthcare organization should apply when they feel they are ready for certification. On PMPN.7 #1 about the pediatrician: If we have no in house neonatologist, can telemedicine be used? We are a level II NICU/OB and our sister hospital is a level III, can we consult the neonatologist at those facilities? Is there a minimum number of births required to be eligible for this certification? Was the American College of Nurse Midwives included? Does Certification require 100% of PC core measures vs. a sample size? PNPM.7, EP1: states a neonatologist must be available for consultation. Acceptable methods of consultation should be defined by the organization and their policies (see PNPM.3, EP11). Yes. Per the Perinatal Certification general eligibility guidelines, the program must have served a minimum of 10 patients at the time of their review. Yes. ACNM was represented on the Technical Advisory Panel and also provided feedback on the requirements during the field review. The Perinatal Care measures should be collected and reported in the same way for the certification program as they are for the accreditation program. Sampling is optional for PC-01, PC-02, PC-03 and PC-05. Sampling is not an option for PC-04. Further details on the sample sizes can be viewed in the Specifications Manual for Joint Commission National Quality Core Measures V2015A1 at:

10 Do the measures address service delivery for Moms when they are "transferred in" from a lower acuity setting? The emphasis appears to be about transferring Moms out to a higher acuity maternity level. PCC sites receive transfers from Home Birth and Birth Centers. April 28, 2015 In general the requirements apply to any patient in the certified perinatal program including those patients who enter into their program via transfer, referral, etc. There are some specific-expectations in the standards that reference those facilities who receive transfers from other perinatal programs: having a relationship and communicating with those programs who transfer mothers/newborns to their organizations (see PNPC.5, EP 11). The facility receiving the transfer should communicate the outcomes of the mother/newborn transferred to the transferring program for the purposes of the transferring program's process improvement (see PNPI.2, EP 1; see also PNPI.5).