3701-83-58 Quality assessment and performance improvement.  

  • Text Box: ACTION: Final Text Box: DATE: 04/14/2011 9:39 AM

     

     

     

    3701-83-58                  Quality assessment and performance improvement.

     

     

     

    (A)  Each exempt center shall monitor and evaluate the provision of direct care services to its patients and shall implement procedures to improve the quality of care and resolve identified problems. The quality assessment shall, at minimum, include:

     

    (1)   The review of all transfers of patients to a hospital or other health care setting; and

     

    (2)    The review of complications and adverse events during the provision of the exempt center's services.

     

    (B)    As part of the quality assessment and performance improvement activities and to assist the director in determining if the exempt center is in compliance with rules 3701-83-57 and 3701-83-58 of the Administrative Code, each exempt freestanding birth center shall report to the director of health, as may be required, but not less frequently than annually January 20th of each year, the following information and data in the format and manner prescribed by the director and appendix A of this rule:

     

    (1)   The identification of the administrator or director of patient services of the birth center;

     

    (2)      The identification of the physician(s) providing obstetrical or pediatric consultation and oversight to the exempt birth center staff, and number of patient care-related contacts initiated by staff;

     

    (3)     Staffing of the exempt birth center, including the number of traditional midwives, apprentice midwives, certified professional midwives, and any state-licensed health care professionals;

     

    (4)     How and by whom potential patients are being assessed for risk prior to admission;

     

    (5)   The total number of patients seeking admission and total number admitted;

     

    (6)   The total number of post delivery admissions, the reason for admission, and the length of stay;

     

    (7)   The number of deliveries at the exempt birth center;

     

    (8)   The number of deliveries by a physician, a certified nurse midwife, a certified

     

     

     

    professional midwife, an apprentice midwife, or a lay midwife;

    (9)   Identification of who attended each delivery within the exempt birth center;

    (10)   The total number of live births by weight in grams;

    (11)    The total number of newborns where estimated gestational age was less than thirty-seven weeks and the total number of newborns where estimated gestational age was greater than forty-two weeks;

    (12)   The total number of fetal, neonatal, and maternal deaths;

    (13)   The total number of maternal transfers to a hospital obstetric service or other health care setting; whether before or following delivery; the reason for transfer; the date of the transfer; and the name of the receiving entity; and

    (14)    The total number of neonate transfers to a hospital newborn service or other health care setting; the reason for the transfer; the date of the transfer; and the name of the receiving entity;

    (C)     The  data  submitted  under  this  rule  shall  be  reviewed  by  the  exempt  center's consulting physician prior to submission.

    Effective:

     

    R.C. 119.032 review dates:

    04/24/2011

     

    02/07/2011 and 02/10/2016

     

    CERTIFIED ELECTRONICALLY

     

    Certification

     

     

    04/14/2011

     

    Date

     

     

    Promulgated Under:

     

    119.03

    Statutory Authority:

    3702.301

    Rule Amplifies:

    3702.301

    Prior Effective Dates:

    6/1/2007

Document Information

Effective Date:
4/24/2011
File Date:
2011-04-14
Last Day in Effect:
2011-04-24
Five Year Review:
Yes
Rule File:
3701-83-58_PH_FF_A_RU_20110414_0939.pdf
Related Chapter/Rule NO.: (1)
Ill. Adm. Code 3701-83-58. Quality assessment and performance improvement