Maternal Program

Maternal Program 1. There shall be a written commitment on behalf of the entire facility to the organization of neonatal and maternal care. The written commitment shall be in the form of a resolution at the time of application passed by an appropriate quorum of the members of the governing authority. Should the business organization be other than a corporation, a letter explaining such, together with the written commitment of the hospital’s chief executive officer, to the establishment of a maternal care program may be sufficient. The maternal program must be established and recognized by the medical staff and hospital administration. The maternal program must come under the direction of a family medicine physician or an obstetrics and gynecology physician, with obstetrics training and experience, and with privileges in maternal care. The administrative structure must minimally include an administrator, Maternal Medical Director (MMD), Maternal Program Manager (MPM), and appropriate support staff. The Maternal Program must be multidisciplinary in nature, and the performance improvement evaluation of this care must be extended to all the departments involved. The program must provide perinatal system leadership if acting as a regional center in areas where Level IV facilities are not available. 2. Compliance with the above will be evidenced by but not limited to: a. Governing authority and medical staff letter of commitment in the form of a resolution; b. Written policies and procedures and guidelines for the care of the maternal patient; c. Defined maternal team and written roles and responsibilities; d. Appointed Maternal Medical Director with a written job description; e. Appointed Maternal Program Manager with a written job description; and f. A written Maternal Performance Improvement plan.