(Holly) Hello, everyone, and welcome to today's webinar:
Announcing New Advanced Perinatal Certification.
Before we get started, I'd like to go over a few items,
so you know how to participate in today's event.
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When you joined today's webinar,
you selected to join either by phone call or computer audio.
If for any reason you would like to change your selection,
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You may send in your questions at any time.
We will collect these and address them during the Q&A session
at the end of today's presentation.
The slides are available
in the Handout section of the control panel,
and the recording of this webinar and the copy of the slides
will be sent to you via email.
I will now turn it over to Lindsay Parker Krivanek,
Associate Director, Hospital Certification,
at The Joint Commission.
(Lindsay) Awesome. Thank you so much, Holly.
Thank you and welcome, everyone.
We have a very big turnout for today's webinar,
and we are so excited about that.
As Holly mentioned,
my name is Lindsay Krivanek.
I'm one of the Associate Directors of Hospital Certification
at The Joint Commission.
I will be your host for today's webinar,
and we are all very excited to talk to you about our new program,
Advanced Certification in Perinatal Care.
Before we dive into the agenda,
I want to introduce my colleague and dear friend
Loren Salter,
Associate Director of Hospital Certification
at The Joint Commission.
Loren?
(Loren) Thank you so much, Lindsay.
Hi, everyone, and thank you for joining us today.
I'm Loren Salter,
and I'm one of the Associate Directors of Hospital Certification
here at The Joint Commission.
I am so excited for our webinar today
because the launch of this new certification
is very near and dear to my heart.
I think we're all probably aware of the challenges that we are facing
with poor maternal health outcomes
and increasing maternal morbidity and mortality.
What can we do to improve these statistics?
I wanted to share a little bit about myself
and share a little bit about my "why."
I have a few pictures here on the screen,
each of these taken after the delivery of each of my sons.
In one picture,
just moments before,
my son was fighting for his life.
In the other picture, just moments before,
I was fighting for my life.
With each of my pregnancies and deliveries,
I experienced complications,
and I'm so thankful for the quick actions
that my nurses and doctors took
to keep both myself and my sons alive.
I was lucky.
The reality today is that not every mom is going to be as lucky as I was.
I was lucky enough to walk out of that hospital.
My husband is lucky to have his wife still here
and to not have to worry about raising two sons alone.
My sons are lucky to have a mom who is alive
and who will get to see them grow up.
I was lucky.
As individuals in the perinatal community,
we need to fight for our moms and babies.
We need to advocate for their health,
from prenatal care all the way through postpartum care.
Why do these statistics around maternal health
have to be the status quo?
Why does this have to be the norm?
There are maternal deaths that are preventable.
So what can we do?
I think certification is a great first step,
and today, you'll get to hear
about our new Advanced Certification in Perinatal Care
and how it can be a tool that your hospital can use
to help improve outcomes
related to maternal mortality and morbidity.
I want to thank you all for jumping on today
and taking that initiative
and advocating for moms all across the US.
We need to make a change, and this change can start today.
It can start with you.
I'm going to ask why should we pursue
the Advanced Certification in Perinatal Care?
Lindsay, if you can go to the next slide, please?
For me! (chuckles)
So moms can see their children's first birthday
and celebrate Christmas with their family,
so the fathers and partners don't have to raise their children without a mother.
These boys are my "why."
This is why I am advocating
for our Advanced Certification in Perinatal Care,
so that every mom and baby gets a fighting chance
and because I don't want expecting moms
to think that "I was lucky" is good enough.
Thank you for letting me share my "why" and share my story.
I think I speak for not only myself
but for all the mothers out there, all the partners out there.
Thank you for taking action to help improve
our maternal outcomes across the US.
Lindsay, I'm going to hand it back over to you. Thank you.
(Lindsay) Loren, thank you so much.
Thank you for sharing your story, being so vulnerable,
and sharing your beautiful boys with us.
We love them so much.
Thank you.
Now, we'll segue into the agenda for today.
A quick glance at the agenda.
Jennifer Anderson--
she's the Department of Standards and Survey Methods
at The Joint Commission--
is going to discuss the requirements
and talk about the on-site review process.
Then we're going to hand it over to Chris Walas
who is the Managing Project Director
for Clinical Department of Quality Measurements
with The Joint Commission,
and she is going to walk you through the standardized measures.
I will close out the session
and talk to you about details on how to become certified.
We'll always use any remaining time we have
to answer any questions
that are submitted in the chat.
Just to do a quick level set here,
our new Advanced Certification in Perinatal Care--
it's a long name,
sometimes we'll use the acronym, ACPC--
will launch on January 1st,
and our current Perinatal Care Certification
is being phased out.
We expect that the new Advanced Certification in Perinatal Care
will really help push organizations even further
on that quality continuum.
We are always delighted and so thankful
to be able to collaborate with our partners at ACOG,
the American College of Obstetricians and Gynecologists.
Now I'm going to hand it over to Jen Anderson,
and she's going to take you through some details on the standards.
(Jennifer) All right. Thank you, Lindsay, and thank you, Loren.
I am so impressed
with those color-coordinated glasses with each outfit.
That was amazing.
I have two in glasses too, so they're always adorable.
Thank you, everyone.
I'm really excited to be here to talk to you today
about this new Advanced Certification, or ACPC, program.
My background is perinatal clinical nurse specialist,
so anything OB-related
has technically and figuratively been my baby
for the last five years since I've been here--
pun intended.
I'm just excited to be able to share any information that I can
around this very important topic.
We're going to talk a little bit and level set
around our current environment for maternal care.
As you all know...
We'll go to the first graph here.
that our trends
for pregnancy-related mortality and morbidity
are going in the wrong direction.
This graph that I have here is even a little bit outdated
because things have not gotten better in the United States.
When we look at the graph after this one,
we can talk even more related about race and ethnicity
and the ratios amongst our African-American pregnant moms
and comparing them to their white counterparts,
and how they're three to four times more likely to experience
some sort of harm or even death during pregnancy.
When you compare us in the next graph to nations
outside of the United States, other industrialized nations,
we are going the absolute opposite direction of everyone else.
This has gotten a lot of media attention
as we can see in the next coming pop-outs here.
Basically, we have writers, media experts,
calling us out, saying, "We know what to do.
Hospitals know how to protect their pregnant patients,
and they're just not doing it."
Many articles written about people who weren't so lucky like Loren,
husbands or partners raising children without their mothers.
Really, Joint Commission recognized that we needed to do something.
When I started back in 2017,
this was the current environment.
If you can go ahead and click on the next slide, please.
Another representation, again, an older graph,
showing that mortality related to pregnancy
based on years
and where we compare to different countries.
Next slide.
I think sometimes it's just really important
to be able to see these things in pictures.
Here we have overall rates of morbidity and mortality,
and you can see that compared to 20 years prior,
we've really significantly jumped.
Sometimes people tend to believe
that this is because we've been paying more attention to hemorrhage.
We've been really focusing on hemorrhage in some states
since the 2009 time frame.
This slide I really like
because it separates out blood transfusions
from the SMM rate,
and still shows
that we've significantly increased our morbidity and mortality,
and it continues to grow.
Next slide, please.
Again, just another representation, this one's a little bit more current,
talking about the number of deaths per 100,000 live births
based on race and ethnicity.
We can just really see that we're not getting any better
when you compare to some earlier graphs that I showed
in relation to the disparities in our African-American
and Indigenous patients.
Next slide.
We rank right now, depending on what statistic you look at
and what article you read,
roughly around 65th among industrialized nations.
As I mentioned,
we have some moms
that are three to four times more likely to experience harm or death.
One of the interesting things about that statistic
is, traditionally, when you think of disparities,
we look at socioeconomic status,
and we look at education status,
and that's not the case.
This statistic, when we compare our African-American moms
and their white counterparts, really, it doesn't matter.
Whether you have those socioeconomic pieces
are not as important for this population.
The most recent statistic,
I believe we had over 800 maternal deaths in 2020.
Obviously, we know that it's probably significant
with COVID rates in there,
but definitely way more deaths each year than any other industrialized country.
To Loren's point,
it's actually more dangerous for women to deliver today
than it was for their mothers when they delivered.
Next slide, please.
Joint Commission decided that we really needed to do something
to address maternal safety.
Why? Why did we decide that?
We recognized that there was really no standardization across the states
related to maternity care.
We knew some states five years ago
were really focusing on those quality collaboratives,
and there were some that had been around for many years.
There are some states that didn't have any quality collaboratives at all--
that's thankfully changing as we speak today.
Often, many hospitals overestimate their capabilities to care for sick moms.
Women of childbearing age are getting sicker and sicker
and don't seem to be improving--
that's obesity rates, hypertension rates.
Also, children back in the '80s
who ten years prior may not have been able to survive
are now surviving,
and then they're bringing along their health complications
and having babies
as they're just getting sicker and not any better.
Then this national media attention focusing on these poor outcomes
and the little that was being done about it.
We decided that we really needed to take a step in this arena.
Next slide.
Back in August of 2019,
we implemented or announced
that we would be requiring two new standards
for our hospital program.
This is the first time
that Joint Commission had ever specifically addressed
the patient population within the requirements.
We are known for having requirements
that can be broadly used across multiple populations,
but these are two requirements
that are specific to our maternal patients,
and it's preventing maternal harm for hemorrhage
and preventing maternal harm
for severe hypertension and preeclampsia.
We first started surveying these back in January of 2021.
Now that we've been doing this for about a year and a half or so,
we have some really good data
on where we can further improve related to our hospital program.
If we click on the next animation that I did here,
you'll see that back in December of 2021,
VP Harris had called--
Maternal Health Call to Action Day
actually called out these two requirements
in our hospital program
as best practice
and listed what we call R3
as an important resource for organizations to help improve maternal care.
That was really exciting.
Next slide, please.
As Lindsay mentioned,
we've been really excited to collaborate
with the American College of Obstetricians and Gynecologists.
We started our work with them
when we were working on the two requirements
for our hospital program.
Recently, last year,
we launched our Maternal Level of Care Verification.
We've also been working really closely with them
with this Advanced Certification in Perinatal Care
that is due to launch on January 1 of '23,
which is going to be here before we know it.
Next slide.
As some of you may be aware,
we are sunsetting our Perinatal Care Certification.
Without the foundation that that awesome certification provided,
we most definitely would not be where we are today
with ACPC,
so thank you to everyone who participated in our PNC program
and allowed us to take that foundation
and just take it to the next level where we really need to go for our moms.
We looked at the PNC certification,
and we identified some key concept gaps
based on current quality and safety issues.
We identified experts that we could work with
to talk about those gaps
and to talk about some key strategies on how to overcome those gaps,
and identified some best practices that are available
that we can incorporate into this ACPC's requirements
to help hospitals be compliant with the requirements
that we put forth.
Next slide.
Some of the gaps that we identified...
This work was being done over probably a six-month period
with ACOG in our clinical provider work group that we had.
We started with a small work group with ACOG.
One of the things that we wanted to make sure we addressed
is in the PNC program,
we really talked about focusing on the uncomplicated pregnancy.
Knowing the current state in maternity care,
we knew we needed to incorporate more complications
within the ACPC program.
We wanted to talk about safety section practices
and call those out.
Focus on substance use disorder.
As we know that that's one of the next leading cause of death
now that we focused on hemorrhage and hypertension.
We know that mental health and substance use
are also leading causes of death among this population
that are preventable.
We've started looking at those health-related social needs,
and then really started talking about outcome stratification
by race, ethnicity, and primary language.
Next slide, please.
We held a technical advisory panel
with many key stakeholders--
I couldn't even list them out here on this slide--
which we completed in March of 2022,
so just a couple months ago-- feels like forever ago--
but we worked with the Society of Maternal-Fetal Medicine, ACOG.
We pulled in our nursing colleagues
with the Association for Women's Health, Obstetric, and Neonatal Nurses-- AWHONN.
We worked with family practice providers,
multiple midwives providers,
anesthesia, and the list just really goes on and on.
We had pediatricians at the table.
We really brought all key stakeholders to the table to talk about the next steps.
Next slide, please.
After, in our normal process,
we hold these technical advisory panels--
we call them our TAPs.
They help us inform draft standards,
and that's what we put out to the public.
I'm hoping some of you were able to participate in that.
We had open comment-- public comment--
from mid-April to mid-May of this year.
We found that the new requirements were well received.
Then we also wanted to make sure that we engaged our current PNC customers,
so they got a personal invitation
to participate in what we call "Standards Review Panel"
so that they could also provide us feedback
that was a little bit more geared towards current state versus future state
and what their thoughts were.
On the next slide,
you will see that we finalized those requirements,
and we announced the new program
in July of this year.
My goal for the next part of this presentation
is to talk about some of these new requirements.
I'm not going to read them to you.
You'll have an example of...
You'll get the slide deck in your email,
but just some of the key differences
between those gaps that we identified
and how we incorporated them into these requirements.
You'll see...
We like our abbreviations at Joint Commission.
The way that we write our requirements,
the names here, we include the program and then the chapter.
This is our ACPC manual,
and it's our Program Management Chapter
and our third standard and Element of Performance 14.
We really wanted to incorporate
some elements of the AIM C-section bundle
because we know that AIM is considered some best practices
that are available to organizations,
so we wanted to incorporate some pieces
about safe C-section practices.
You'll see-- you're probably doing most of these things--
implementing a standardized criteria for admission and triage,
making sure that staff and patients are educated about spontaneous labor;
talking about some standardized techniques
for pain management and comfort measures;
using those standardized methods for communication
to talk about fetal heart rate and interpretation;
and promoting freedom of movement--
working with your providers and your nursing staff to allow movement,
depending, obviously, on conditions for mom and baby;
and then adopting protocols to look for specific problems
that may warrant a C-section,
but making sure that you've got those protocols in place
and that your providers and your nurses are educated on all of those.
On the next slide, just some examples
on how we incorporated work with substance use disorder.
We really focused on the ability for the organization
to perform those risk assessments and screenings
not just related to substance use but also mental health,
domestic violence--
other things that we would anticipate we would need to screen for;
looking at the treatment of substance use if we do find a positive screen,
and then also incorporating the newborn into that
and how do we manage that newborn withdrawal,
is our staff confident in assessing for that,
and then how do we make sure babies getting the treatment that they need;
and then also doing those pain control protocols
and making sure we're individualizing those,
so not just for some patients who have a history or current substance use,
but those who may have other complex medical histories
that may need some extra thought
with pain control protocols.
Next slide.
Some more requirements for substance use
just because it is such a focus currently:
making sure that staff is trained and competent
in caring for these patients,
particularly related to bias and stigma,
making sure that we're not discriminating against this population;
making sure that individuals are referred for support services,
and that they have consultation and referral,
and trying to help coordinate that piece for the patient when possible;
making sure that they're using appropriate assessment tools
that have been validated,
such as appropriate pain scales,
appropriate prenatal and postpartum forms,
especially related to those health-related social needs
in relation to the substance use disorder screening and protocols.
Next slide.
Mental health, same sort of thing:
making sure that not only are we assessing
for any history of mental health
but current issues with mental health
and working with the community providers,
so the prenatal providers,
but then also those community resources;
and making sure that everybody has information
about who is available to help care for this patient population.
It's using that interdisciplinary approach
to identify these patients
and how do we get them the help that they need
through consultation or referral.
It's really just making sure
that we have this universal screening in place,
and then what do we do when we have that positive screen,
how can we help the patients,
and then also, how can we help the providers
with those appropriate resources.
Next slide.
This is a few of the requirements
that really talk about the hospital organization
being that coordinating hub:
making sure that the community perinatal providers
have appropriate education
related to the importance of treatment and referral
for patients with known or suspected mental health disorders,
helping them know what resources are available in the community.
The hospital also helping to coordinate that care
for treatment after discharge with those community resources.
So helping patients identify those community resources,
talking with those community resources
to let them know that they've got patients
that may be seeking their services
and making sure that they're keeping a list of appropriate referrals
and people who are accepting patients
with their condition related to pregnancy,
which we know sometimes can be difficult.
Helping patients identify
some coping strategies
and using trauma-informed care
when we're doing these assessments and caring for patients
because we know that pregnancy and delivery can be traumatic in itself,
but when patients have that history of some sort of trauma,
pregnancy and delivery may be a triggering event,
and so making sure that we're using that trauma-informed care
so that patients are a) seeking care when they need it
and b) when they are seeking care, they're being cared for appropriately.
Next slide.
Health-related social needs
is something that's gotten a lot of attention within Joint Commission
over the last year,
and it's continuing to grow.
The hospital program,
at the same time that we were announcing
this ACPC program,
they also announced new requirements for health-related social needs.
We wanted to coordinate with them
to make sure that our two programs aligned.
This is making sure that organizations are assessing
every pregnant or postpartum patient
for any health-related social needs
to see if there's anything that the organization can do to help
to make sure that patients have access to care.
This is just an example of some of the things
that you may be assessing for,
but there may be others depending on your patient population
and the community that you serve.
Next slide, please.
Some more requirements here that we talked about
is the consistency of getting the information by using assessment tools
that have been approved by the leadership team.
I think I talked about this one already,
so I'll skip that one.
Again, this is the faci--
Can't talk right now!
The facilitating access to those community resources,
not only for mental health substance use
but also to help meet these health-related social needs.
Next slide, please.
Outcome stratification.
This is a relatively new one,
but this is one
that our expert panel was very vocal about:
the importance of understanding
disparities within your pregnant or postpartum patient population.
This is requiring organizations to look at their performance measurement data
by race, ethnicity, and preferred language
just as the first step to see
okay, maybe we're having issues with preferred language
in treating patients appropriately
for whatever the performance measurement data is
that you're collecting,
but really looking at that so that you can make improvements
based on these known disparities.
Next slide, please.
All right, everyone wants to always know
what is it look like when you come on-site.
It's the same exact on-site survey process
that we had for our PNC certification.
It's one or two reviewers for two days.
It depends on the size of your nursery, the level of nursery that you have.
If you have a level I or II nursery, it would be one reviewer for two days.
If you have a III or IV, it will be two reviewers for two days.
All of these reviewers are experienced in obstetrics and nursery,
so we're able to talk the talk and walk the walk.
We know what you were going through,
and we're excited to talk to you about your program
and learn best practices from you
and also share best practices that we've seen around the country.
Some sample agenda includes an opening conference,
just like we do currently.
We do those system tracers that you're familiar with.
We'll look at HR, competency, and training for your staff
and then credentialing for your providers.
We'll do those unit tours where we get to talk with the staff
and do those individual tracers
where we'll follow a patient through their care continuum.
If necessary, we'll have an issue resolution
where we can talk through findings,
and then you'll have a closing before we leave.
Next slide, please.
Some of our on-site survey goals
are to look at your clinical practice guideline.
When you apply for ACPC,
you'll be asked to identify some of the best practices that you use
to inform your policies and procedures.
When we're looking at a patient who is induced for postdates,
we'll pull up your induction policy,
and then we'll compare that policy to your actual practice.
Then when we're looking at the policy,
we're checking to see what evidence-based guidelines you used
in order to develop that policy and procedure.
We will assess the compliance with those policies and procedures
by interviewing patients,
interviewing your staff and other personnel.
We will look at your performance improvement plan
and offers suggestions and education and best practices as we can.
Next slide.
Again, I'd like to share those evidence-based practices.
We assess staff education.
If your policy says that your staff needs to be competent
in whatever it may be,
we'll make sure that they've had that appropriate training
and competence check.
We look at the leadership roles and that shared decision-making,
your culture of safety,
and we also like to see what your patients are receiving
as far as education on different conditions,
when to seek help, and those sorts of things.
Next slide.
After we leave and before we leave,
you will know exactly what is on your opportunities for improvement,
what's exactly on your report.
We use the SAFER Matrix
just like we do for our hospital program,
but there will be no surprises when our reviewers walk out the door.
Once you receive the official document from our central office,
you'll have 60 days to submit an Evidence of Compliance summary--
an ESC, we call that.
Then once it's accepted,
you'll be given a letter
stating that you've been certified in our ACPC program,
and you can celebrate and share it with whoever you'd like.
The certification is good for two years with an intracycle monitoring process
that Chris will talk about a little bit.
Next slide.
As I mentioned, Chris, perfect timing.
Chris is a Managing Project Director
in our Department of Quality Measurement.
She is going to talk to you
about the performance measures.
It's off to Chris. Thank you.
(Chris) Great. Thanks so much, Jen.
Next slide, please.
I will be discussing the measure criteria
within the certification process.
The Advanced Certification in Perinatal Care
has new eligibility requirements,
and these requirements are provided in full detail
in that certification manual,
but I wanted to highlight and go through them
to give you some information and background.
The Perinatal Care site must have a minimum of 40 deliveries per year.
In addition, the Perinatal Care site
must have a minimum of 30 total denominator cases
for the data used in calculating aggregate performance rates
to meet threshold criteria on all applicable measures.
More on the threshold criteria soon
because that is a new function in ACPC.
The Perinatal Care measures specifications
are publicly available
and found on The Joint Commission website.
In ACPC, the Perinatal Care program is required to collect data
on all chart-abstracted Joint Commission Perinatal Care Core Measures.
This includes PC-01: Elective Delivery,
PC-02: Cesarean Birth,
PC-05: Exclusive Breast Milk Feeding,
and PC-06: Unexpected Complications in Term Newborns.
These sites also need to use these measures
for ongoing performance improvement efforts.
At least four months of measured data
must be available at that initial certification review.
For recertification, it's 24 months of data that is required
since it's a two-year renewal cycle.
Threshold requirements will be applied to PC-02: Cesarean Birth
and PC-06: Unexpected Complication in Term Newborns, Severe Rate Only.
The data used to calculate and enter performance strength into your application
must be available at the time of initial certification on-site review.
For recertification,
organizations must continue to meet the threshold criteria
for applicable measures, which is only PC-02: Cesarean Birth
and that Severe Rate Only for PC-06,
and that recertification,
there would be the most recent 12 months of data required
to calculate those aggregate performance rates
and update your application.
Next slide.
Let's look at these measure thresholds for the initial certification.
Organizations must meet these threshold criteria:
an aggregate performance rates
for both PC-02 and PC-06, Severe Rate.
Organizations will be reporting on all of the Perinatal Care measures.
However, threshold criteria
are required for PC-02 and PC-06, Severe Rate Only.
You'll still submit your data on the overall rate and the moderate rate.
However, only the Severe Rate will have that threshold criteria applied.
The organizations must submit the sum of the numerators
and the sum of the denominators in E-App
using four to twelve months of the most recent data available
for both PC-02 and PC-06, Severe Rate.
The E-App will perform the calculation to provide the organization
the aggregate performance rate,
which must meet the following threshold criteria:
aggregate denominator cases must total at least 30 cases
for each performance rate calculated;
PC-02 Cesarean Birth must have an aggregate performance rate
of less than or equal to 30%;
PC-06 Severe Rate,
the aggregate performance rate must be less than 50 severe complications
per 1,000 live births--
the aggregate rate is multiplied by 1,000 in the calculation
because the PC-06 rate is reported
as the number of severe complications per 1,000 live births.
The aggregate performance rate calculation
is provided on the slide to allow organizations
to determine their aggregate performance rates.
However, as mentioned before,
in the E-App,
the organization will provide
the sum of numerators and sum of denominators,
and then the calculation will be done automatically for the organization.
Next slide.
For recertification,
certified organizations must meet the same threshold criteria
for performance rates on both PC-02 and PC-06, Severe Rate.
The sum of the numerators and denominators
must be submitted in the E-App at recertification.
However, you would use 12 months of the most recent data available
for these measures.
The E-App will also calculate the aggregate performance rate.
Next slide.
Now we will look at measures in the review process
for Advanced Certification in Perinatal Care.
For the initial certification,
the organizations will submit their data for performance rates into the E-App
and the test on Tab 3 that they understand performance rates for PC-02
and PC-06 Severe Rate,
must meet threshold criteria,
be entered into the application
and the data be provided at the initial on-site review
for validation.
As mentioned before,
the sum of the numerators and the sum of denominators
will be entered by the organization,
and the E-App will calculate the performance rates.
The aggregate performance rate, again, for PC-06
will be multiplied by 1,000,
so it will be presented to the organization
as the number of severe complications per 1,000 live births.
If the organization tries to submit an E-App,
a denominator less than 30
or a performance rate is calculated that is above the thresholds,
an alert will be provided to the organization
to have them contact their Account Executive.
The organization will not be able to save and submit their application.
The organization would then have two options:
to withdraw their application
or push out the ready date and collect more data.
If the organization successfully submits their application,
they must provide the data they use
to calculate their aggregate performance rate
during the on-site visit.
The initial review, organizations can use 4 to 12 months of data
to calculate their performance rates.
Some organizations already collect on these measures
and may have 12 months of data available.
However, since ACPC is open
to non-Joint Commission-accredited organizations,
a minimum of four months is acceptable to be used
in the performance rate calculation
as long as they have at least 30 denominator cases total
and meet threshold criteria.
Four months matches the amount of data required to be provided
at the on-site review for initial certifications.
Next slide.
The intracycle review process will continue to include
data review, resources, and quality improvement discussions.
New with ACPC
will be a measure threshold discussion with all organizations
to ensure they are aware of the threshold requirement
for recertification eligibility
and what those threshold levels are.
It's important for the organization to understand
what performance rates they are at
and what their trends are
to ensure that they'll meet that threshold criteria
at recertification.
Reviewers can offer resources
to encourage quality improvement processes.
Next slide.
For recertification,
the same process will be used as the initial certification
to allow for consistency.
Organizations update their performance rates
by entering the sum of the numerators and the sum of the denominators
for the most recent 12 months of data in E-App.
Rates will be calculated in E-App,
and the same eligibility requirements apply for recertification.
Next slide.
Trend reports are available in CMIP,
which will be providing the organizations
with their submitted numerator and denominator cases.
In the future,
we are in the works of developing an ACPC new dashboard,
which will be available on The Joint Commission extranet site
for certified organizations.
Accelerate PI reports will also be included in the future,
which will provide aggregate rates for a rolling 12 months of PC data,
and the PC dashboard will also include new visual graphs and charts for PC data.
Finally, comparison data will also be provided
when enough data is available to make those comparisons.
Next slide.
Great. I'll now turn it over to Lindsay.
(Lindsay) Wonderful. Thank you so much, Chris.
Thank you, Chris and Jen. That was a great overview.
What I'm going to talk to you all about today
is the steps to getting ready to apply
and some of the tools and resources and things that you'll need to begin.
If you're ready to get started,
my overarching message is reach out to certification@jointcommission.org
You will be connected with your Associate Director.
We have a team of individuals just like myself and Loren
who are here to help you
throughout the entire certification process.
It's our job. We'll provide you with all the resources you need.
Make sure you have access to E-dition,
just walk you through each step.
Again, reach out to certification@jointcommission.org
What we'll do is during our first call or the first time we connect,
we'll make sure that you have access to the standards
where you'll want to perform a gap analysis,
see how your program currently compares to the standards,
and that'll help us set up a timeline.
We will also help you prepare for the application
by identifying your clinical practice guidelines.
There is a short five-question performance improvement plan
that we will walk you through as well.
As Chris mentioned,
we'll help you make sure you have the right data in place,
the most recent 4 to 12 months of data available
for the PC-02 and PC-06.1
that meet the threshold criteria,
and we'll walk you through that.
For all of the preapplication or the application components,
we have templates available,
so you can essentially work on the application
before you're even ready to apply.
One of the big questions is always timeline,
so just talking about the timeline.
We ask that you submit your application
about four to six months before you would like your on-site review to occur.
This is an initial survey.
You will have a 30-day notice when the review is scheduled.
so there's plenty of time.
We want you to be excited.
We want you to know that we're coming out
and that you feel ready for us to come out.
Let's see what I have.
The application.
The application is available in the Connect portal.
As we've mentioned, it will be available as of January 1st.
If you are not currently accredited with The Joint Commission,
or maybe you don't have access to this Connect portal,
then, again, reach out to your Associate Director,
and we will assist you with obtaining access
and make sure that you can log in.
Many of you are ready to apply,
and many of you have already taken the opportunity
to submit a preapplication.
That's wonderful.
We have a preapplication available today.
This means you can go ahead and get in the queue.
You can reach out, again, to your Associate Director,
or you can also locate this preapplication right on our website.
A few things coming up next.
We have our launch event that is scheduled for November 10th.
We are going to have more details to come out.
You can expect a similar format
with some exceptional additional speakers as well.
Then, again, the ACPC launches on January 1st.
I wanted to move through that portion pretty quickly,
so I could go through some of these questions
that we have in the chat.
But first, let me put it on this page.
I'll leave this slide up,
so you can jot down any phone numbers or email addresses that are necessary.
I'll just scroll up through the questions,
and we'll get through as many as we can.
If we do not get to your question in the time that we have remaining,
then please contact us.
If you know your Associate Director, go ahead and reach out
or respond to the email address that I repeated a zillion times.
Let's start with the first one.
Jen, I'm going to give this question to you.
It is related to...
The question is "Does the collaboration
between OB and ICU
need to be done via written protocols?"
(Jennifer) No, we don't specifically call out
the ICU and OB collaboration,
but we do have a requirement
that talks about the program follows its written policies
for consultation and transfer agreements.
Not necessarily that they have to be written protocols
between ICU and OB,
but we do require them for consultation and transfer agreements,
if that helps it make sense.
My guess it would be some sort of policy
that says when you have to get your ICU involved,
but nothing that has to be super formal.
(Lindsay) Perfect. Thank you.
Then this next question
is around comparing the rates of obesity, diabetes, smoking, hypertension,
other unhealthy habits
that we are betting are much higher in our country
compared to other countries.
Do we have this data available?
To answer this question,
if you would please contact us after the webinar
at certification@jointcommission.org
We think we have this data.
It might take a minute to pull together,
but we would like to connect with you
and make sure that we send this over to you.
Moving on.
Let's see. Jen, I think this... Yes, this will go to you.
"How will you survey to requirement..."
Let me see. "How will you survey to requirement
to educate the community providers
and to prove we are providing transportation
and other social assistance?"
(Jennifer) When we come out on-site, we could talk to those providers,
the community perinatal providers,
if they're available at the hospital,
and just talk about the collaboration
that you have with the community providers,
or we can even...
Say, you provide an open in-service for your docs
during a monthly med staff meeting or something,
or you provide them with a handout with community resources
that are available for substance use for pregnant patients--
stuff like that,
that just shows that you've been working together,
and same thing with the community resources.
Are you maintaining a list of who's accepting patients,
as far as how do we assess if you're giving transportation assistance
or food assistance or something like that?
You don't necessarily have to provide that transportation assistance,
but if you're giving them the resources to your local public health department,
I would assume that you would document that
in the medical record somewhere.
Whether your social worker does that, or your nursing staff does that,
that would be how we would more likely look for that,
would be documentation in the medical record for that piece.
It was a multipronged question.
I hope I answered each piece, Lindsay.
- (Lindsay) Yes, I think that was great. - (Jennifer) Okay.
Chris, I'll head to you at this question.
This is about data, and I may be able to jump in as well.
The question is
"Will you roll any existing current data
that is in the Perinatal Certification,
CMIP,
into the Advanced Certification,
or do we have to start over?"
This organization is already certified in the PNC program.
"Are we going to be able to look at the data that's already entered
and roll that into the new certification?"
(Chris) Sure.
We do allow you to use that data.
However, it will need to be submitted
into your application in the E-App,
so it won't automatically transfer to the ACPC program.
However, the data that you have already been collecting on,
you certainly may use that
to enter into your E-App
and then provide that data on-site during the review.
(Lindsay) Yes. Absolutely.
It will be a new application when you apply for the ACPC,
and that's something also
that your Associate Director can help you gather
and move that data from your PNC to your new ACPC.
Okay, the next question is
"Will a recording of the webinar be shared?"
It will be shared, and the slides as well,
so everyone will have access to that.
This is a comment, and I think this is a great comment.
"I love that you included mental health and substance use disorder as a focus.
Since we have good data
on the contribution of racism to healthcare outcomes,
it would have been great to have an intentional focus
on becoming antiracist organizations.
We are looking at stratifying that data and looking at that in detail as well."
That was a comment that we received.
Let's see. We talk through the benchmarks.
Chris, if you wouldn't mind just going through the benchmarks
one more time
for the two measures, that would be great.
- (Chris) Sure, the measure thresholds. - (Lindsay) Yes, thresholds.
Again, just to clarify:
data will still continue to be reported
on all of the chart-abstraction measures.
However, as part of the eligibility requirement
PC-02: Cesarean Birth,
organizations must meet the threshold criteria
of having a Cesarean birth rate of 30% or less
and a PC-06: the Unexpected Complication in Term Newborns, Severe Rate Only.
Again, you'll still be submitting and collecting data on PC-06,
which has the Overall Rate, the Severe Rate, and the Moderate Rate.
However, for eligibility,
only the Severe Rate will be looked at
to ensure that the threshold criteria
is being met,
and that criteria is 50 severe complications or less
per 1,000 live births.
(Lindsay) Perfect.
Then a few more questions.
This one is "If we are transferring to the new certification,
Advanced Certification in Perinatal Care,
from the old, the Perinatal Care Certification,
should we continue to work with our certification specialist
or start over with the certification email group?"
Go ahead and reach out to your certification@jointcommission.org
or reach out to your Associate Director,
and we will get you started.
We're going to want to make sure that you have the latest standards.
We'll also be there to answer questions about the data, the thresholds--
all of that good information.
"If we are already Perinatal Care-certified,
do we reapply or will we go ahead with our intracycle call?"
Each organization is unique.
You have multiple options.
I would say just to keep it brief, reach out to your Associate Director,
and they'll be able to talk you through
based on when your intracycle conference call is coming up.
If you want to go ahead and apply
for the Advanced Certification in Perinatal Care,
you absolutely can.
You don't have to wait
until your current Perinatal Care certification expires,
but we'll look at that in detail with you.
Let's see.
This is a data question also.
"The 30 total denominator cases,
is this 30 cases in a month or in four months?"
(Chris) That is 30 denominator cases total.
If you're using four months of data,
it would be adding each month's denominator,
and that total four months must be 30 cases.
That's why if you don't have enough within four months,
you can continue to collect data
until you meet that 30 denominator criteria
because it's an aggregate rate,
so we're summing up the monthly denominator totals
until you get to that 30 or 12 months.
(Lindsay) Awesome.
Another question: "For those that have completed the preapplication,
is there another application to complete later or in January?"
That's a great question.
There is.
You have completed the preapplication,
which is essentially your intention to apply and move forward,
helps us with scheduling, and really gets you in the queue,
so you can be one of the first to be surveyed in early 2023.
You still will need to go in
and complete the actual application in the Connect portal,
which will open up in January.
That's where we'll ask for a few additional items of information,
such as your clinical practice guidelines
responding to the PI plan,
and we'll want to enter the data
for the measures that's been discussed.
There is an application portion in January.
For everyone that's completed a preapplication,
your Associate Director will be in touch with you as well
to make sure that you have everything you need to complete it
in the online portal in January.
It looks like this might be the...
Let's see.
This might be the last two questions, but, Jen, this one is for you.
"Does the ultrasound tech have to be in-house 24/7,
or can they be on call?"
(Jennifer) One thing that we did a little bit differently this time around
is that we leave that up to you.
If your organization needs an ultrasound tech in-house 24/7,
you would say that in your policy.
If you have a requirement that they have to be available 24/7
but can get to you within 30 minutes,
that's acceptable as long as it's in your policy.
We don't get super specific as far as those sort of things.
We just say what basic ancillary-type staff
needs to be available 24/7.
What available 24/7 looks like is up to the organization.
(Lindsay) Perfect.
Then let's see.
There's going to be questions that we have not gotten to for today.
If we did not get to your question-- I just got a question on tracing
and, again, on the presentation slides and more about the preapplication--
please reach out to us after this webinar
at the certification@jointcommission.org
Let's see if we can slide one more in really quick.
It was a... Let's see.
Here, again, this is one on tracing.
I lost it.
Well, I lost the question.
So I'm sorry.
I'm sorry we didn't get to all of these questions today,
but we thank you so much for joining.
Thank you for joining this presentation.
Thank you to all the wonderful speakers,
to Loren, to Jen, and Chris,
and to everyone that's taken interest
and is being an active contributor to this new certification.
I hope you all have a great day.