Performance Improvement: The facility must have a documented PI Plan

Performance Improvement: The facility must have a documented PI Plan. The maternal program must measure, analyze, and track quality indicators and other aspects of performance that the facility adopts or develops that reflect processes of care and is outcome based. 1. The Chief Executive Officer, Chief Medical Officer (or Chief of Staff), and Chief Nursing Officer must implement a culture of safety for the facility and ensure adequate resources are allocated to support a concurrent, data-driven maternal PI Plan. 2. The facility must demonstrate that the Maternal PI Plan consistently assesses the provision of maternal care provided. The assessment will identify variances in care, the impact to the patient, and the appropriate levels of review. This process will identify opportunities for improvement and develop a plan of correction to address the variances in care or the system response. An action plan will track and analyze data through resolution or correction of the identified variance. 3. Maternal facilities must review their incidence and management of placenta accreta spectrum disorder through the PI Plan and report the incidence and outcomes through the Perinatal Multidisciplinary Committee. (see guideline) 4. The Maternal Medical Director (MMD) must have the authority to make referrals for peer review, receive feedback from the peer review process, and ensure maternal physician representation in the peer review process for maternal cases. 5. The MMD and the Maternal Program Manager (MPM) must participate in regional PI regional initiatives and submit requested data to assist with data analysis to evaluate regional outcomes as an element of their maternal PI Plan. 6. The facility must have documented evidence of maternal PI summary reports reviewed and reported by the Perinatal Multidisciplinary Committee that monitors and ensures the provision of services or procedures through telehealth and telemedicine, if utilized, is in accordance with the standard of care applicable to the provision of the same service or procedure in an in-person setting. 7. The facility must have documented evidence of maternal PI summary reports to support that aggregate maternal data are consistently reviewed to identify developing trends, opportunities for improvement, and necessary corrective actions. Summary reports must be provided through the Perinatal Multidisciplinary Committee, available for site surveyors, and submitted to the department as requested.