77 Ill. Adm. Code 264.2450
Quality Assurance and Improvement
Section 264.2450Â Quality Assurance and Improvement
a)
A
birth center shall implement a quality improvement program consistent with the
requirements of the accrediting body and is encouraged to participate in
quality improvement projects implemented by the Department's Administrative
Perinatal Centers and other Department-supported perinatal quality improvement
projects.
(Section 35 of the Act)
b)Â Â Â Â Â Â Â Â The
birth center shall adopt, implement, and enforce a written quality assurance
and improvement program that includes all health and safety aspects of client
care for both pregnant or postpartum persons and infant.
c)Â Â Â Â Â Â Â Â The
ongoing monitoring and evaluation of the quality and accessibility of care and
services provided by the birth center or under contract shall include, but not
be limited to:
1)Â Â Â Â Â Â Â Â Admission
of clients appropriate to the capabilities of the birth center;
2)Â Â Â Â Â Â Â Â Client
satisfaction, complaints, and grievances;
3)Â Â Â Â Â Â Â Â Review
of the clinical records;
4)Â Â Â Â Â Â Â Â Incidences
of morbidity and mortality of postpartum person and infant;
5)Â Â Â Â Â Â Â Â Postpartum
infections;
6)Â Â Â Â Â Â Â Â All
transfers to a referring hospital for delivery, care of infant, or postpartum
care of birthing person;
7)Â Â Â Â Â Â Â Â Incidents,
problems, and potential problems identified by staff of the birth center,
including infection control;
8)Â Â Â Â Â Â Â Â Any
issues of unprofessional conduct by any member of the birth center's staff
(including contractual staff);
9)Â Â Â Â Â Â Â Â The
integrity of surgical instruments, medical equipment, and client supplies;
10)Â Â Â Â Â Â Client
referrals and consultations;
11)Â Â Â Â Â Â Appropriateness
of medications prescribed, dispensed, or administered in the birth center;
12)Â Â Â Â Â Â Problems
with compliance with any federal or State laws;
13)Â Â Â Â Â Â At
least an annual review of protocols, policies and procedures relating to
maternal and newborn care;
14)Â Â Â Â Â Â Appropriateness
of the risk criteria for determining eligibility for admission to and
continuation in the birth center program of care;
15)Â Â Â Â Â Â Appropriateness
of diagnostic and screening procedures;
16)Â Â Â Â Â Â Quarterly
meetings of clinical practitioners to review the management of care of
individual clients and to make recommendations for improving the plan of care;
17)Â Â Â Â Â Â Regular
review and evaluation of all problems or complications of pregnancy, labor and
postpartum and the appropriateness of the clinical judgment of the clinical
practitioner in obtaining consultation and attending to the problem; and
18)Â Â Â Â Â Â Evaluation
of staff on ability to manage emergency situations by unannounced periodic
drills for fire, maternal/newborn emergencies, power failure, etc.
d)Â Â Â Â Â Â Â Â The
birth center shall identify and address quality assurance issues and implement
corrective action plans as necessary. The outcome of any corrective action
plans shall be documented. The outcome of the remedial action shall be
documented.
e)Â Â Â Â Â Â Â Â The
QAPI shall include, but not be limited to:
1)Â Â Â Â Â Â Â Â Routine
testing of the efficiency and effectiveness of all equipment (e.g.,
sphygmomanometer, dopplers, sterilizers, resuscitation equipment, transport
equipment, oxygen equipment, communication equipment, heat source for newborn,
smoke alarms, and fire extinguishers);
2)Â Â Â Â Â Â Â Â Routine
review of housekeeping procedures and infection control; and
3)Â Â Â Â Â Â Â Â Evaluation
of maintenance policies and procedures for heat, ventilation, emergency
lighting, waste disposal, water supply and laundry and kitchen equipment.
f)Â Â Â Â Â Â Â Â The
QAPI program shall monitor and promote quality of care to clients and the
community through an effective system for collection and analysis of data, which
includes, but is not limited to:
1)Â Â Â Â Â Â Â Â Outcomes
of care provided:
A)Â Â Â Â Â Â Â Spontaneous
abortions;
B)Â Â Â Â Â Â Â Neonatal
morbidity;
C)Â Â Â Â Â Â Â Maternal
morbidity;
D)Â Â Â Â Â Â Â Persons
registered for admission for care;
E)Â Â Â Â Â Â Â Antepartum
transfers;
F)Â Â Â Â Â Â Â Â Persons
admitted to birth center for intrapartum care;
G)Â Â Â Â Â Â Â Intrapartum
transfers;
H)Â Â Â Â Â Â Â Number
of births in the birth center;
I)Â Â Â Â Â Â Â Â Percentage
of breastfeeding persons;
J)Â Â Â Â Â Â Â Â Births
occurring en route to the birth center;
K)Â Â Â Â Â Â Â Postpartum
transfers;
L)Â Â Â Â Â Â Â Newborns
transferred;
M)Â Â Â Â Â Â Type of
delivery; normal spontaneous vaginal delivery or other;
N)Â Â Â Â Â Â Â Third
and fourth degree lacerations;
O)Â Â Â Â Â Â Â Infants
with birth weight less than 2500 grams or greater than 4500 grams;
P)Â Â Â Â Â Â Â Â Apgar
scores less than 7 at five minutes;
Q)Â Â Â Â Â Â Â Neonatal
mortality; and
R)Â Â Â Â Â Â Â Maternal
mortality.
2)Â Â Â Â Â Â Â Â Reasons
for transfer:
A)Â Â Â Â Â Â Â Antepartum;
B)Â Â Â Â Â Â Â Intrapartum;
C)Â Â Â Â Â Â Â Postpartum;
and
D)Â Â Â Â Â Â Â Newborn.
g)
Clinicians,
or their clinical representative, attending persons in labor at the birth
center shall attend morbidity and mortality reviews that occur at the receiving
birthing hospital on their clients, when invited, at a mutually agreeable
time. This includes, but is not limited to, maternal and neonatal
clients
transferred to the receiving birthing hospital.
(Section 35 of the Act)