3701-83-42 Quality assessment and performance improvement.  

  • Text Box: ACTION: Final Text Box: DATE: 04/22/2016 10:12 AM

     

     

     

    3701-83-42                  Quality       assessment        and      performance        improvement     - freestanding birthing centers.

     

     

     

    (A)   As part of the quality assessment and performance improvement program required under rule 3701-83-12 of the Administrative Code, each freestanding birth birthing center shall evaluate the provision of direct care services for to the mother mothers and newbornnewborns who receive care from the center. The evaluation of direct care services shall, at a minimum, include:

     

    (1)     Development and evaluation of risk criteria for determining eligibility for admission to and the continuation of care for a mother and newborn in the birth center program of care;

     

    (2)    Documentation and review of complications and adverse events which arose arise during the provision of the center's services including complications of pregnancy, labor and the postpartum period;

     

    (3)   Review and evaluation of the management of care;

     

    (4)     Evaluation of the appropriateness of diagnostic and screening procedures including laboratory studies, sonography, and non-stress tests;

     

    (5)     Evaluation of the appropriateness of medications prescribed, dispensed or administered in the birth center;

     

    (6)   Review of all transfers of mothers and neonates newborn to a hospital, health

    care  provider,  or  other  health  care  setting

    or  provider  to  determine  the

    appropriateness and quality of the each transfer;

    (7)    Development of discharge criteria for the mother and the newborn patients served by the center;

    (8)    Regular review of medical records including a review for of legibility and completeness;

    (9)   Annual review of all protocols, policies and procedures relating to maternal and newborn care provided by the center;

    (10)   Review of the maternal and newborn assessment procedures as they impact on quality of care and cost to the patient;

    (11)    Review of the provision of emergency services including services listed in

    paragraph (C) of rule 3701-83-34 of the Administrative Code; and

    (12)      Evaluation of the center's compliance with local, state, and federal requirements and national standards of care related to the provision of care to mothers and newborns.

    (B)    As part of the quality assessment and performance improvement program required under paragraph (A) of rule 3701-83-12 of the Administrative Code, each freestanding birth center shall report to the director:

    (1)   The total number of women who delivered;

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

    (3)   The total number of fetal deaths;

    (4)   The total number of neonatal deaths;

    (5)   The total number of maternal deaths;

    (6)   The total number of emergency cesarean-sections performed including:

    (a)   The total number of primary cesarean-sections, and

    (b)   The total number of repeat cesarean-section;

    (7)    The total number of attempted vaginal births after a previous cesarean-section and the total number of successful vaginal births after a cesarean-section;

    (8)    The total number of newborns whose estimated gestational age is less than thirty-seven weeks, and the total number of newborns whose estimated gestational age is greater than forty-two weeks;

    (9)   The total number of maternal transfers to an obstetric and newborn care services service including;

    (a)   The total number of transfers prior to delivery, and

    (b)   The total number of transfers after delivery;

    (10)     The  total  number  of  patients  seeking  admission  and  the  total  number  of patients admitted.

    Effective:

     

    Five Year Review (FYR) Dates:

    07/01/2016

     

    02/16/2016 and 02/15/2021

     

    CERTIFIED ELECTRONICALLY

     

    Certification

     

     

    04/22/2016

     

    Date

     

     

    Promulgated Under:

     

    119.03

    Statutory Authority:

    3702.13, 3702.30

    Rule Amplifies:

    3702.12, 3702.13, 3702.30

    Prior Effective Dates:

    1/13/1996, 6/27/96, 9/5/02, 4/24/11

Document Information

Effective Date:
7/1/2016
File Date:
2016-04-22
Last Day in Effect:
2016-07-01
Five Year Review:
Yes
Rule File:
3701-83-42_PH_FF_A_RU_20160422_1012.pdf
Related Chapter/Rule NO.: (1)
Ill. Adm. Code 3701-83-42. Quality assessment and performance improvement