Neonatal Program

Neonatal Program 1. There shall be a written commitment on behalf of the entire facility to the organization of neonatal care. The written commitment shall be in the form of a resolution at the time of application passed by appropriate quorum of the members of the governing authority. Should the business organization be other than a corporation, a letter explaining such, together with a written commitment of the hospital’s chief executive officer, to the establishment of a neonatal care program may be sufficient. The neonatal program must be established and recognized by the medical staff and hospital administration. 2. The neonatal program must come under the direction of a practicing pediatrician, family medicine physician or a physician specializing in obstetrics and gynecology with experience in the care of neonates/infants and with privileges in neonatal care; 3. Neonatal Medical Director (NMD), Neonatal Program Manager (NPM), and appropriate support staff. The Neonatal Program must be multidisciplinary in nature and the performance improvement evaluation of this care must be extended to all the departments involved. 4. 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 neonatal patient; c. Defined neonatal team and written roles and responsibilities; d. Appointed Neonatal Medical Director with a written job description; e. Appointed Neonatal Program Manager with a written job description; f. Analysis and review of system perinatal outcome and quality data; and g. A written Neonatal Performance Improvement (PI) plan.