(Loren) ﻿Hello, everyone, and welcome to today's Launch Event
for Advanced Certification in Perinatal Care.
Before we get started,
I'd like to go over a few items,
so you know how to participate in today's event.
First, if you are having issues with the webinar audio
or are having trouble hearing,
please use an ethernet connection
or close down apps on your device to open up more bandwidth.
You have the opportunity to submit your questions
by typing them into the Questions pane of the control panel.
You may send in your questions at any time.
We will collect these and are going to address them
during the Q&A session at the end of today's presentation.
The agenda and slides are available
in the Handouts section of the control panel.
A recording of this webinar and a copy of the slides
will be sent to you via email after the event.
I will now turn it over to Brian Enochs,
Executive Vice President,
Business Development and Marketing at The Joint Commission.
Brian?
(Brian) Good day to everyone
from what has turned out to be a truly glorious fall day
in the Chicago area.
I just wanted to take a few minutes today
on, what for us, is a very special day to say a few words of welcome
and to initially thank all of you all
for the time that you agreed to give us today
to have what we think it's going to be--
or what we hope is going to be a very important discussion for you.
Just a couple of things I want to do today.
I want to, first of all, explain why this is an important day for us
and by extension, I hope, a very important day for you all as well.
The Joint Commission,
a year/year and a half go,
has gone through the process of determining
where we want to make some very critical commitments
from a mission perspective
to the improvement of our quality and safe care
across the country.
We identified,
a couple of years ago,
this area, the area of Maternal Care,
as something that's going to be very important to us today,
tomorrow, and well into the future.
That started us down a path
that initially began with an outreach to ACOG,
our partner in this endeavor.
A series of discussions
that we use to determine how we can best drive improvements
in quality and safe care in this area.
You all are probably aware of the first step we took
in that regard.
Last year, when we launched
our Maternal Levels of Care Verification program,
that was an initial step,
not so much from a quality and safety perspective,
but quite frankly, from more of a public health perspective.
The idea of that program
was to ensure that the right patient gets to the right facility at the right time,
and it was really designed for large geographic areas
or large organizations
so that they can help optimize their Maternal Care
across multiple sites.
That is available to anyone who's interested in learning about it
and potentially participating in the program,
and we've gotten some extremely strong and very positive feedback
on that program initially.
But what we're talking about today,
Advanced Certification for Perinatal Care
is the second step in that journey for us,
and in many ways, it may be more important
because this really is an opportunity for us
to look closely at quality and safety
and really drive improvements in those two spaces
with a program that's both voluntary
and one that actually is designed
to help distinguish what we would hope to be recognized
as the top providers in the country with regard to Maternal Care services.
This really is a second and very critical step
in the pursuit of the priority that we identified almost two years ago
and have partnered with ACOG to make a reality.
My hope is that as we go through
the process today of talking about this program,
talking about why we think it's going to be critical,
talking about why we think you all, hopefully, will participate,
please keep in mind that this is something
that we've decided to make an organizational commitment to.
It's a collaborative organizational commitment with ACOG.
If we're successful here,
and if we can get your help,
we can make this ubiquitous recognition across this country
for what, hopefully, will be truly recognized as the top providers
with regard to Maternal Care across the United States.
That really is, I think, from an introductory perspective,
why we think this is so important
and why we're so delighted that we have so many people
joining us today online for the program.
Again, I want to thank you for your presence.
The second thing I want to do, real quickly,
is to thank a series of people.
First of all, the folks that had put all the work
into making this a possibility.
These webinars and these programs are not simple
to organize and to launch,
and there's a whole host of people
here at The Joint Commission who've worked very hard to bring it to you.
I want to thank you all for the work that you've done.
Just as important, however,
I really wanted to extend an expression of gratitude to our partner, ACOG,
who's been in our side every step of this journey
for quite some time.
We would not be here without their support and their help.
I just can't thank you all enough for the spirit of partnership
in which we've been able to move forward along these lines.
I'm so glad to to have ACOG here with us today,
which is the third thing I wanted to do.
We are extremely lucky today
to have Dr. Christopher Zahn as our keynote speaker for this program.
I wanted to take just a second to introduce Chris
and tell you a little bit about him.
I can tell you that The Joint Commission
and I, by extension, have been working with
and having the privilege of partnering with Chris
for quite some time now.
He's just...
The fact that he's here today,
we're extremely grateful to have him.
Dr. Zahn is currently Chief of Clinical Practice,
Health Equity, and Quality
at ACOG.
He's a retired Air Force officer
and a member of ACOG's Armed Forces District.
He received his medical degree
from the Uniformed Services University of the Health Sciences
and is a specialist in Comprehensive Obstetrics and Gynecology.
He's been practicing for 25 years.
Before joining ACOG, Dr. Zahn was professor
and Chair of Obstetrics and Gynecology
at the Uniformed Services University of Health Sciences
and a staff physician
in the Departments of Obstetrics and Gynecology and Pathology
at Walter Reed National Military Medical Center
in Bethesda, Maryland.
He was also the Program Director
of the Uniformed Services Residency in Obstetrics and Gynecology,
a maximally accredited tri-military service residency
in Obstetrics and Gynecology
under the auspices of the National Capital Consortium
at USUHS.
Dr. Zahn has also been a member of the ACGME Review Committee
for Obstetrics and Gynecology
and is a former member of the Board of Directors
of the American Board of Obstetrics and Gynecology.
We're so delighted to have Christopher here.
We feel particularly privileged
that he's agreed to deliver the keynote remarks here.
My hope is that the time that we have today
is seen as truly valuable by all of you
that we can have a great discussion about the merits of the program
and answer any questions that you might have.
Without further ado,
I want to thank you again for being here.
I want to welcome Chris as our keynote speaker today.
Thank you very much.
(Chris) Thank you very much, Brian.
Thank you for the very kind words and the introduction
and for sharing the story of the partnership
that we'll talk a little bit more about.
I feel a little guilty that I'm listed as the keynote speaker.
Quite honestly, I think my presentation is probably the least important information
that you're going to hear today,
but we do appreciate everybody attending to this
and for your dedication to improving the health care
and outcomes of the patients that we serve.
This will just be a really brief introduction
into the current ACPC Program,
but to also give a little bit of the history of the partnership
that Brian touched on as well.
Next slide, please.
Why are we here? Why are we on this webinar?
Why have we partnered with The Joint Commission?
Why is everyone interested in this?
This pretty much sums it up.
Our statistics are not very good in this country.
I think that's pretty well-known,
pretty widely known,
by a number of different communities,
not the least of which is our government
and certainly our patient groups
and the clinical societies.
Our mortality rates have gone up.
There is, appropriately so,
nationwide efforts
by a number of different organizations and other entities
to try to address this problem.
We know it's a multifactorial problem
that's going to require multiple resources to address,
but it obviously is a continuing problem and a critically important problem.
Next slide, please.
Some recent data published by the CDC also addresses
the causes of maternal mortality based on the findings
of the Maternal Mortality Review Committees.
Some of these are probably not new to many of us.
We've known for a long time that hypertensive disease,
VTE, infection,
hemorrhage certainly are significant contributors
to maternal mortality,
but others have surfaced to be significant contributors,
including mental health conditions,
which has grown to be a significant contributor
to maternal morbidity and mortality
as well as cardiac disease, particularly cardiomyopathy.
Certainly, one of our bigger advocacy efforts
over the last few years
is to expand the coverage for postpartum services out to a year.
The reason for that is because some of these contributors to mortality
actually are more common
once you get beyond those first six weeks in the postpartum period,
particularly cardiovascular disease can occur out to a year postpartum,
so it's really critical
that we incorporate that extended time period
if we're really going to had a significant impact
on reducing maternal mortality.
Next slide, please.
How did this all start?
The levels of Maternal Care document, the clinical guides,
was originally published in 2015
with the Society for Maternal-Fetal Medicine,
our most recent revision was published in 2019.
Basically, this provides a framework for regional hospital relationships
as well as a description of the facility's capabilities,
resources, and personnel.
In fact, if you really think about it,
prior to the publication of the original document,
really, there was no framework at all
as far as what hospitals should consider having
from their resources, from their equipment,
from the personnel, from anesthesia support,
from radiology support, etc.
It was really completely individualized and independent.
This really, again, provided the framework
for facilities to really consider what their resources were
and then, hopefully, to identify
what patients were safe for them to take care of.
The purpose of levels of care was to reduce morbidity and mortality
by ensuring that facilities are prepared to provide risk-appropriate care.
"Risk-appropriate" is the key word there, the key set of words.
Part of it is to encourage development
of collaborative relationships in the regions
so that patients once identified
as more complex than a particular facility to care for
that they can get that patient to the facility
that had the resources necessary
to be able to escalate.
If they were going to be escalated,
that there was a seamless process to arrange that.
There's nothing more uncomfortable
than having a complicated patient, but you don't have the resources.
You have no idea where to go or where you can send the patient.
It's all about care at the right place at the right time.
Next slide, please.
After the documents were published,
we thought we need to make this more than a piece of paper.
We need to translate this into an implementable program.
At the time, we knew that the CDC had their LOCATe tool,
which is aligned with the Levels of Maternal Care,
but, really, a resource for facilities
to look at their resources and share that information at the state level.
But, at the time, early on,
we decided to pilot the verification program,
basically, a site-survey program.
We could go visit facilities
and verify what their resources and capabilities were
to categorize those facilities in the different levels.
While we were doing the verification,
we learned of Texas actually passing legislation
to implement Levels of Care Verification program.
The Maternity Designation program was legislated, as mentioned,
and ACOG launched the Verification program in Texas in 2018
that has been very successful.
While we were developing the Texas program,
we actually started some conversations with The Joint Commission.
The initial conversation actually reached out
about some of the Alliance for Innovation on Maternal Health, the AIM, bundles,
but as we started talking,
there was more discussion about Levels of Maternal Care
and the growing interest in that program and its background.
We started talking about the program
over time,
developed the Verification program.
We knew, at the time, that there were several states or healthcare systems
that were interested in participating in the program.
Also, there was definitely a growing interest
in Levels of Maternal Care,
both in what ACOG was doing
as well as what The Joint Commission was developing with that partnership.
Next slide, please.
After the standards were developed and a lot of work--
as Brian has mentioned, this is a tremendous amount of work
by both the folks at The Joint Commission
as well as ACOG to get the program together--
the collaborative launched in January of 2022.
Why did we do this collaboration?
We know that The Joint Commission's mission
is to improve health
and to help organizations to provide safe and effective care.
Our overall goal certainly is to improve care for women
as it is for The Joint Commission and so many other organizations,
but we clearly had a focus on risk-appropriate care
and quality improvement,
but we realized, in developing the Texas program,
that basically, it's not our business.
We're not resourced
to develop a large-scale, site-survey-quality type of program,
but The Joint Commission is.
The Joint Commission has the infrastructure
to facilitate widespread implementation of a program like this
over very short time.
The Joint Commission has a long-established series of programs
and certification and accreditation.
Again, they have the infrastructure to do this that we never did,
even though we were obviously interested in expanding Levels of Care nationwide.
We thought that this was really a great partnership
to combine the efforts of expanding Levels of Maternal Care
with The Joint Commission who had the infrastructure
to be able to expand that very readily.
Next slide, please.
After the the Levels of Maternal Care program launched,
we started some discussions about the ACPC program.
This is a totally separate program from Levels of Care Verification.
It really extends the prior Perinatal Care Certification program,
which existed actually before our collaboration
with The Joint Commission ever started.
There were roughly 60 hospitals
that participated in that initial Perinatal Care program,
but there was interest in developing an advanced program.
The Joint Commission surveyed the number of hospitals.
There was a lot of interest in pursuing advanced certification.
Even by hospitals not participating in the original program,
there was interest in participating in an advanced program.
Next slide, please.
You'll certainly hear more about this
in the remaining part of the presentation,
but the areas to be highlighted in the ACPC
are the scope of practice,
the patient care and services,
quality improvement,
activities, the leadership and the clinical staff,
the equipment and the staffing,
use and implementation of evidence-based guidelines,
but the focus is really on quality improvement,
addressing disparities,
how data is used to monitor the practices and quality
to look at their safety, look at communication,
are social and structural needs being identified,
information about substance use and the focus on outcomes
with an emphasis really on the high-risk areas,
that contribute to maternal morbidity and mortality,
and, certainly, with an emphasis on integrated and coordinated care
that's patient-centered,
and using, again, outcomes and performance measurement
to drive improvement.
Definitely, it's probably oversimplified to say it this way
but ACPC is focused on outcomes and quality improvement and safety,
whereas Levels of Maternal Care focuses more on the facilities,
capabilities, and available resources.
Next slide, please.
The standards were developed--
and you'll hear more from Jen Anderson about that
with the partnership with ACOG and The Joint Commission--
it was reviewed with representatives from multiple hospitals
to help refine the standards as well as the process.
The advanced certification will replace the current Perinatal Care certification,
and the plan is to launch in January,
so pretty soon.
We're very excited to pursue this program
as well as continued programs.
Again, we appreciate everybody's dedication
for the number-one goal for all of us here,
that is to improve maternal outcomes.
Thank you again. I'm going to turn it back over.
Hopefully, I'll be back on for some questions and answers later on.
(Loren) Great. Thank you so much, Dr. Zahn.
We appreciate your support.
Now, I am going to turn it over to Jennifer Anderson.
She is the Associate Director
in the Department of Standards and Survey Methods,
and she is going to give a program and standards overview.
Jen, I'll hand it over to you.
(Jen) All right. Thank you so much, Loren.
As Loren mentioned, my name is Jen Anderson.
I'm an Associate Director
in the Department of Standards and Survey Methods.
What my team does
is we create, develop, revise, delete--
we know people like when we delete--
requirements for every single program that we offer,
whether it's a certification or it's a part of hospital accreditation.
Someone on my team has had their hand in it.
Then after we develop or revise standards, then we figure out
what does this look like when we're on-site
and how do we assess for compliance with these requirements.
I've been so lucky
to have been able to be a part of all of these perinatal initiatives
since I started with Joint Commission five years ago.
My background is a perinatal clinical nurse specialist.
I've really been able to bring my passion for OB services to The Joint Commission,
and it's just been a really exciting time to be here.
Thank you again for participating today.
I'm really excited to share all of the work that we've done
over the last couple of years,
but in particular, related to this new advanced program.
I'm really excited,
and I hope that you're excited as well
that we're focusing on this area of healthcare.
Next slide, please.
As Dr. Zahn mentioned,
we know the current environment for Maternal Care
is not where we want to be.
Our morbidity and mortality continues to rise
for all of our maternal patients,
but most particularly,
for our African-American pregnant and postpartum patients,
so we continue to watch the data.
It just becomes more and more grim every year.
There's been even more recent data that's come out
that our outcomes have continued to decrease.
Joint Commission decided back in 2018,
this was really an area that we needed to focus on
just because of some of the statistics that have been coming out,
the fact that other industrialized nations are improving,
yet we continue to not improve and to actually get worse.
Back in 2018,
we started to work on some initiatives.
We knew that this was starting to get national attention.
As you can see here on the screen,
that an article series had been published,
starting in 2018,
about the fact that moms were dying in hospitals
and claiming that "We knew what to do,"
and nobody was holding these organizations accountable.
We really started to do a deep dive into the current status
and figure out what we can do to improve.
Next slide, please.
Just another reiteration of the fact
that we continue to get worse as everyone seems to get better,
just highlighting the fact that we really needed to do something.
This is what we've come up with.
Next slide, please.
I really like this slide.
I know it's a little outdated,
but this is the overall rate of SMM
between 1993 and 2014, so definitely outdated,
but I like this slide because we pulled out blood transfusions.
Back around 2019, there started to be...
I'm sorry, 2009-- way long ago--
we started to really focus in on maternal hemorrhage.
Some states had had quality initiatives including California.
I was practicing in Illinois at the time.
We really started to focus in on maternal hemorrhage
and what we can do to prevent harm related to hemorrhage.
I like that this slide pulls out blood transfusions
because, as you all know, back in 2009,
it was three units of blood or more to equal morbidity.
Now, it's different-- different definition--
but we really started to focus in on how to treat hemorrhage.
Even when we exclude those blood transfusions
as a severe morbidity,
our rates are still continuing to increase,
and, if not, they're even worse now.
Next slide.
This one is a little bit more current
where it definitely highlights the continuing growth of disparities
for our African-American--
It doesn't highlight our Indian-American moms,
but, definitely, the fact that we're continuing to increase
at an alarming rate for our African-American moms
related to deaths.
Next slide.
As Dr. Zahn mentioned, our outcomes are not good.
Depending on what literature you look at,
we rank around 65th
among industrialized nations for maternal morbidity and mortality.
As I mentioned, African-American and American-Indian mothers
are three to four times more likely to experience harm or death
during pregnancy or postpartum.
700 deaths a year.
I believe the most recent number was over 800 deaths for 2021,
could be even higher,
and it's more dangerous for women to actually deliver today
than it was for their mothers.
Next slide.
Again, why The Joint Commission get into this space?
If you're familiar with our accreditation requirements,
you know that they're written rather broadly
so that whether you're in an ICU unit or event surge
or a pulmonary care unit,
you're able to apply those standards and Elements of Performance
to any patient population.
With our PC requirements
that we implemented back in 2019,
we, for the first time, focused in on a specific population.
This was when we required the hemorrhage and hypertension standards
that Dr. Zahn had mentioned--
and I'll get into those a little bit--
but we decided that, after looking at all those statistics,
looking at that data,
the national attention that we were getting for our outcomes,
we did some research to determine, really, what was going on,
so we recognized that there's really no standardization across the states.
What California and some of these other states
that had really established quality collaboratives were doing
was really important and really making strong improvements,
yet not every state back in 2018 had quality collaboratives.
I'm grateful to know that that's improving
and more and more states have quality collaboratives.
It's hard to say when you're trying to say it a lot of times.
But that has changed.
We know that most states now have that,
which is awesome, but there are different levels.
Some are just starting off, some are really established.
We knew that there was no standardization across the states.
We knew that hospitals tend to overestimate their capabilities
when it comes to taking care of sick moms.
In Illinois, for a long time,
it was "How many weeks is she? Can we care for this baby?"
before we made any determination about what was going on with the mom.
Women of childbearing age are getting sicker,
and it doesn't seem to be improving,
and, again, that national media attention.
Now, we have attention at Capitol Hill,
really what made us recognize that we needed to do something in this space.
Next slide.
In 2019,
as Dr. Zahn mentioned,
for the most of 2018
and the beginning of 2019,
we really focused in on that low hanging fruit.
What are the two complications
that we know have evidence-based practice guidelines
out there available
that have been shown to improve outcomes?
Most preventable deaths were hemorrhage and hypertension.
They were well-established.
The AIM bundles related to those.
A lot of data supporting some very simple steps
that organizations could put into place in order to improve outcomes.
After working with ACOG so closely and their AIM division
and making sure that we had the right information out there,
the right requirements out there to make a difference,
we announced in 2019 that we would be requiring organizations
in January of 2022 to...
I'm sorry, we did July of 2020
that they were going to be held responsible
for these two new requirements to prevent harm
from hemorrhage and severe hypertension.
We all know what happened in 2020.
We knew that this was a big lift,
but hospitals were also very stressed with the COVID pandemic,
so we pushed the implementation of these back by another six months.
We first started surveying to these requirements in January of 2021.
In the next little animation,
you'll see that in December of 2021
during the Maternal Health Call to Action Day,
Vice President Harris actually had multiple things that she outlined,
steps that we can take to improve Maternal Care.
These two requirements were listed as best practices for organizations.
That was a really proud moment for us
because we knew how important they were,
personally, we really stood behind these
and to have them highlighted in Washington, D.C.,
which is really exciting.
Next slide.
As we were developing these hemorrhage and hypertension requirements
for our Hospital program.
We had started to establish that relationship with ACOG,
as Dr. Zahn and Brian had mentioned.
During this time frame,
we started working on our Maternal Levels of Care,
which is essentially the ACOG OCC document
that's been translated into Joint Commission language--
as you all know, it's a little bit different.
We've started to really market and work with people
regarding this program, which is really exciting.
But the next exciting thing
has been this Advanced Certification and Perinatal Care,
which, as Dr. Zahn mentioned,
we'll be watching in just a couple of months here.
I actually don't know where the time has gone,
but we'll have these two new products that are solely focused on our moms.
It's just super exciting.
Next slide, please.
As some of you may be aware,
because we did have 60 customers in our PNC certification,
which was developed back in 2015, and it was a really good program,
and at that time,
there was really not much attention on Perinatal Care at all back in 2015,
so we needed to figure out what we needed to do
to take our current program and elevate it to the ACPC.
We worked really closely with our clinical practice group at ACOG
and our internal expert group to identify some key concept gaps
that were missing in our current certification.
PNC was focused more on uncomplicated pregnancy,
so we knew we needed to take some steps
and figure out what does the current research show,
what are the current problems,
and identify those gaps,
so we can discuss how to get to where we needed to go.
During our research phase and our conversation phase,
we identified some key experts
that would have an invested interest in this new certification program.
We started to identify them from the research
and from our work with our clinical practice group,
also identified some best practices:
who is addressing some of these gaps currently impacting us,
who is doing some of this work really well--
so we can tap into them and not reinvent the wheel
in some of these things
and really figure out is this doable
because we don't want to create requirements that isn't doable for people.
We want people to be able to strive for this certification
and to achieve this certification.
What gaps are there,
and are there best practices to address those gaps?
That's where we started to get us into our current program.
Next slide.
Some of the gaps that we identified with a ACOG
and that we focused in on with our expert group,
we did this work January of 2022.
We really made some determinations.
How do we get from uncomplicated pregnancy
to encompassing all pregnancies, all complications?
We wanted to make sure we address some safe C-section practices,
particularly looking at the AIM bundle for safe C-section practices,
and we knew, especially with the current data
that's been coming out the last couple of years,
we knew we needed to focus in on mental health
and substance use disorder.
Health-related social needs is huge right now,
as we all know,
and then outcome stratification by race, ethnicity, or primary language,
so really focusing in on those health-related social needs,
and then how do we know
that we don't have implicit bias based on our patient population.
We don't know that unless we stratify outcomes,
so we work towards that as well.
Next slide.
In March of last year,
we held a Technical Advisory Panel.
This is normal part of our standards development process.
Pretty much anytime we have a new requirement
that's considered an above-and-beyond requirement
compared to things that are given to us
through our regulatory partners,
we'll hold the Technical Advisory Panel
where we get the key stakeholders together to talk through some big topics,
which are very mindful to make sure that we have good representation
from all of the major stakeholders
and all of the key players
in whatever patient population or patient problem we're looking at.
We tried to reach out to those who maybe have opposing opinions as well
because we want to make sure...
We know when we put something in front of people,
there are going to be others who oppose the work that we're doing
or may have different ideas
of how they think we could improve outcomes,
so we try to get a good group together
to make sure that we have some really robust conversation.
As you can see, this is just a handful of the key stakeholders
that we had at the table back in March.
It was a great conversation.
I can't thank our key stakeholders enough
that came together to help advise this information and this new program.
I think we have come up with something really great.
Next slide, please.
Another part of our normal process is a field review.
This is where we show the world our draft standards
and where we are going
and what we're thinking of in terms of anything new that we put out,
anything revised that we put out.
Anybody can take the field review.
We post it all over the place.
It was open for four weeks,
mid-April to mid-May.
We take that analysis.
We combine it with another analysis that we do
called a "focused engagement"
or "standards review panel" is another term that we use.
We wanted to make sure
that our current PNC customers felt heard.
We sent them a separate version of the field review,
so that they could comment on the new and revised requirements
and give us some feedback about where they were in their journey,
do they feel that they can meet the new requirements
or do they have some work to do.
We really took that feedback in addition to the field review feedback,
reengaged our Technical Advisory Panel, our Clinical Expert Group,
and did an analysis to figure out if we were in the right spot
related to our requirements.
They were really well-received.
We had very few revisions that we needed to make,
worked really closely with our partners at ACOG
to make sure that everybody was on the same page
and that we were headed in the right direction.
As you can see on the next slide,
we identified all those gaps
and we addressed all those gaps in these new requirements.
I'd just like to spend a couple of minutes here,
just giving you a feel
for what some of these new requirements may look like.
I'm not going to read the screen to you
because there's a lot of information on these screens,
but just to give you an idea of how we address those gaps
that we identified early on in our development phase.
As I mentioned,
we did not address safe C-section practices
in our PNC program,
so we looked to the C-section AIM bundle
to implement some of the practices that have been established
for safe C-section practices
and created new requirements,
particularly for this patient population.
Really quite straightforward.
The program is able to demonstrate the capability
to perform safe C-section practices.
What are we expecting?
We want you to have standardized admission criteria,
triaged management,
education and support for your pregnant patients
coming in in spontaneous labor.
What can we do to support that spontaneous labor?
What are we doing for our patients?
Authorizing standardized techniques
for pain measurement and comfort measurement,
using that standardized language to assess fetal heart rate,
make sure everyone is on the same page
as far as communicating on how the baby is doing,
promoting that freedom of movement,
and having some protocols in place
to address very specific problems,
such as active herpes, fetal malpresentation,
or for patients who can benefit
from some sort of proactive intervention before labor
to reduce the risk of C-section.
If you have a patient who has an active herpes,
what are we doing for them
so that we can, hopefully, promote a vaginal delivery, if possible.
Just looking at your practices
and making sure that we're doing what we can to promote a vaginal delivery.
Next slide, please.
Substance use disorder is sprinkled throughout the manual.
What the root of it is we want to make sure
that there's policies and procedures in place
that support this patient population throughout the entire continuum.
Are we doing those psychosocial risk assessments
and screening on every single patient?
Do we have a way to refer these patients for care?
This is more in particular for mental health
with substance use within this requirement,
but just an example of some of the things that we have
is that universal screening,
having a plan in place if we have a patient that screens positive,
and then what can we do with them,
having some sort of screening and treatment available
for newborns withdrawing,
pain protocols that are individualized,
making sure that just because a patient has a history of substance use,
or we went even a step further
in patients with a history of complex medical pain management.
We aren't just using the same pain protocols
for every single patient,
making sure that it's individualized based on the patient condition.
Next slide, please.
Making sure that your staff and your providers
have appropriate training and competency,
particularly for substance abuse,
looking at bias, stigma, and discriminatory practices.
How are we preventing these things from happening?
Then having some sort of referral system in place
for patients who need these types of services.
You may not necessarily have to be able to provide the services,
but you have to have some sort of referral agreement in place
or referral line,
people that you have available to your patients and to your providers
so that they can get the help that they need,
making sure that the assessment tools
that we're using for screening and for risk
are evidenced-based
and available and approved by leadership.
You're not just using Dr. Smith's tool that he really likes.
Everyone's using the same tool on every single patient.
Next slide, please.
Then mental health.
These go hand-in-hand with substance use disorder.
Many of the same requirements are for mental health
as we have for substance use,
but making sure...
The ones I wanted to highlight here
is that, again, universal screening that goes for mental health as well
and that you're creating this network for your patients and your providers.
Like I said, you may not necessarily have to be able to provide
mental health services for your patient,
but you have a list of providers who can,
and then you're sharing that list
with your perinatal providers in the community,
so they know where to send patients.
Kind of working as a hub
for this patient population, for your providers,
helping them get the information that they need,
and then knowing who you can send your patients to
either peritanally, after delivery,
but having that list of available resources for everybody
is really what the crux of what this is.
You don't have to keep track of the patients
once you've referred them,
but making sure that that referral happens,
that they have appointment,
and trying to help coordinate that for them
because this can be a very--
as we all know, resources are limited,
and it can be very difficult to get the right type of care.
You're part of the group
that's helping them get the care that they need.
Next slide, please.
This is what I was talking a little bit about,
that we are we're educating our community of Perinatal Care providers
to ensure that they're doing the appropriate assessments
in their offices,
and that if they do have patients
that need extra care, extra support,
that they know who they can send them to.
Then after discharge as well, same kind of thing:
making sure that you're keeping up your referral list, that it's current,
and that you have places that you can set your patients to.
All right.
One thing I wanted to point out in this EP 4,
we wanted to talk about trauma-informed care
for this patient population.
It's really important for our patients to make sure that they feel safe,
and that they feel like they're being listened to.
This is another example
of how we're taking in patient's mental health.
I wanted to highlight that requirement,
but you'll find pieces of substance use and mental health
sprinkled throughout the entire manual.
Next slide.
Health-related social needs.
In July of this year,
we announced new requirements for health-related social needs
for our Hospital program, Behavioral Health, and Ambulatory.
They're a part of accreditation,
so we wanted to make sure that we highlighted that
in our ACPC program
because we know that this is a problem for this patient population.
You have to have some sort of screening process in place
to see if there's any health-related social needs
that we can talk about for discharge and for planning,
and your program is able to determine
which health-related social needs you include for your assessment.
These are just some examples of opportunities
that could potentially be options,
but, obviously, you would base this off of your patient population
and your community.
But we are asking organizations to at least have the screening
and that you have very specific health-related social needs
that you're assessing for,
and that you have a plan to address those.
Next slide.
Here's some more about using the same assessment tools,
that these are approved by the leadership team.
I know we've seen that requirement in the other slides,
just making sure that there's consistency
across the entire patient population.
Then, again, talking about helping facilitate access
to whatever the patients may need that may not be providing access.
It's helping facilitate that access.
Next slide.
We have this one requirement related to outcomes stratification.
Many people had comments
about doing more related to this particular area,
but we knew that we needed to start somewhere,
so we landed with this requirement
that the patient population,
the Perinatal Care performance measure data
needed to be stratified by race, ethnicity, and preferred language
because we know that when we identify these topics,
we can see if we have disparities in our outcomes,
but if we're not doing the stratification, we won't know.
This is the information that we're already collecting.
We tried to, like I said, land in a place where it's something,
and we know we have more to do with it,
but this is where we're going to start.
Is this my last slide, Loren?
Okay.
Just one more thing.
I just recognized that I did not mention the fact
that this is open to all critical-access hospitals
and any hospital that delivers babies.
You just have to be compliant with federal/state law,
and CMS Conditions of Participation.
We wanted to highlight the fact
that it doesn't matter how big your organization is.
You can do 100 deliveries a year or you can do 50 delivers a year,
you can do 27,000-- I didn't even know that existed,
but there are hospitals that do 27,000 deliveries a year.
This really focuses on the quality of care that you're providing for your patients.
The best of the best,
the people who are really focused in on quality improvement
and making the care better for your patients.
I wanted to make sure that that was really clear.
It doesn't matter how many babies you deliver a year.
It's all about the quality of care that you're providing to your patients.
Thank you for your attention.
I'm excited to hand it off to Michelle.
She's going to talk about our on-site survey process.
She'll explain-- this is the work that she does.
I know she's excited to talk to you all today.
I'm happy to answer any questions that we may have in the end.
Thank you so much.
(Loren) Thanks so much, Jen.
All right, I'm going to hand it over to you, Michelle.
(Michelle) Perfect. I'm Michelle Arrizola.
I am a former Director of a Level IV NICU here in Chicago.
I work as a partner in the cadre of Perinatal Care.
Next slide, please.
We felt it would be helpful to reinforce
what a survey overview looks like.
The intent is that there will be one or two reviewers assigned
to come out to your organization for two days.
We are all experienced OB and NICU practitioners.
Typically, the agenda includes an opening conference
where we will sit down and give you
some inspiration for the two days that are ahead.
We like to do introductions and share things
that are unique to your organization and your community.
We do system tracers,
which include tracers of your staff files
and your medical files and credentialing,
as well as your data.
We really enjoy hearing you outline how you help,
what your methodology has been
to look at the performance standards that you're measuring.
We typically go on a unit tour
to get a sample of how your organization
welcomes in your parents and families,
and then we split up.
Typically, one of us goes to the Nursery,
and the other would go to Mother/Baby
and look through charts and have conversation with your teams.
We are typically very transparent
as we're going through our review with you all.
If there are any issues that arise,
we typically like to have conversation right in the moment,
so we will do issue resolution.
At the end of the second day,
there would be a closing.
As I here indicated,
our aim really is
that when we're out there on review with you all,
that we're very transparent,
that we're inspirational
and have open conversations with your teams
and really problem-solve how you are attacking,
handling your world of maternal child care.
We make every effort to have it be very meaningful.
We'd like to point out,
we're an extra set of eyes to really determine
whether or not there are any unknown risks
that you may need to mitigate in your organization,
yet we also look for those gold nuggets
and the things that we feel are best practices
from your organizations.
If anyone is on the call,
the organizations that we have been out to,
we typically ask permission to be able to share those gold nuggets
so that others throughout the country would be able to gain your insight
and embrace that into practices that make sense in their community.
We can go to the next slide.
Really, the evaluation itself,
we are really looking for compliance with consensus-based national standards
and how effective you've integrated those
into establishing evidence-based practice in your organization,
how you've integrated them in training,
how you've integrated them into your policies and procedures,
and also, in respect to the data,
how you stratify the data
to really determine not only what overall it means,
but maybe break it down to, say, different ethnic groups
and how they fall out in the data that you provide.
Also, we look for an organized approach
to performance measures and performance improvement
and how you take all of the information
that you have gained
from working collaboratively as a team
and really integrate it.
You can go to the next one.
As I had indicated,
we really like to look for gold nuggets
and share evidence-based practices that we have used or seen
in the organization that we've either been to
or our own personal organizations.
We look at staff education
and have an opportunity while we're doing the tracers
to really have pointed conversations with your teams
and ask them how long have they been there,
what do they enjoy about it,
what their education look like.
We really want to evaluate
how your organization has embraced the national initiatives,
embedded them into your practice
and made sure that as you're onboarding,
whether it be physicians or others in your organization,
into that education piece.
In respect to your data presentation,
it is typically a very active discussion.
We'd like to listen to your metrics
to determine how are you tackling the issue.
Have you really drill down to see
if you move the mark on one thing,
did it impact something else positively or negatively,
and what exactly did you learn?
We look at leadership roles and share decision-making
and your culture of safety
because not just Joint Commission is looking at leading away to zero,
we're really looking at partnering with your organization
to see how you are working together in your community
to really improve outcomes
and get there to zero harm.
As I had said,
not only do we look at staff education,
but we also look at patient education,
and we looked to see
how's that been individualized for that couplet,
how are you ensuring that a mother
whose primary language is not English,
how are you making sure that they are walking away
knowing what they can do and what they should be doing
for the care of themselves and for their infant.
You can go to the next slide.
I wanted to take an opportunity to really talk about
substance abuse disorder as an example of a tracer
that we could walk through.
When Jen presented the substance abuse standard,
she talked about the psychosocial risk assessment screening and referral,
the screening and treatment use of the newborn,
drug withdrawal, and pain control.
We are going to be looking at those specific segments in that metric,
but we're going to be looking to determine how was it addressed in staff education,
how did you embed that in your policies in your organization
and ensure that the specific pieces in respect to substance abuse
were really set in place to be standardized
in your procedures that you have in your units.
We'll review a patient chart.
We'll look specifically at their patient education.
We'll look at a number of different places.
We'll look at the individualized plan of care.
We'll look at your assessment when you onboarded the patient
and determine whether or not everything that that parent had set on admission
you're addressing through their stay
and that it is embracing the policies and procedures that you have.
We evaluate interventions that you're making
and whether or not referral was necessary,
and if referral was necessary,
how is that handed off
to make sure that the outcome is the best for that couplet.
We evaluate consistency of interpretation
and use of your policies and procedures and standards.
One way that a lot of individuals have been able to make this
really embed their practices for their staff,
especially with COVID,
many of us saw a need to use more per diem nurses
or perhaps travelers.
If there's a way that you can utilize your electronic medical record
to really embed what your policies are
so that an individual doesn't have to take time to go into another program
to have it load to figure out what to do in the course of a specific circumstance.
We'll look at your data during the data presentation,
and we'll discuss
how you are actively looking at that metric
and what are you measuring,
and then what does the specific mean
for breaking it down in respect to race, ethnicity,
and taking it as far as if you have a population
that is illiterate or doesn't speak English,
doesn't read at all,
how are you incorporating their need in delivering care.
We'll look at leadership roles
and how decision making is shared
amongst the different individuals
within your organization.
We share evidence-based practice.
We love to take evidence-based practices from you all that are very unique
and share them across the country
to really embrace a commonality
and a standardization across the country.
We review credentialing and privileging processes
specifically related to the maternal child care.
You can go to the next one.
Post visit.
Once we do our closing
and do an overarching analysis
of how the visit went,
what are those positive things that we saw--
maybe where we saw there were opportunities for improvement--
we want to give all of that to you
as we exit your facility.
Then within 60 days of us leaving the organization,
you will get your organization's compliance summary.
Once that compliance summary is accepted by the central office,
the organization is sent a letter,
and it shares with you you're certified
in the Advanced Certification of Perinatal program.
Much like the previous program,
this also is a certification that would be valid for two years
with the intracycle monitoring process as well.
Overall,
I wanted to reiterate what Dr. Zahn had said
that our partnership with your organization
is really us working and partnering with all of you
to focus on the quality improvement,
really addressing how you look at data,
how you monitor it,
in order to provide safe care for your patients
and really improve outcomes.
We look forward to partnerships in the future.
Thanks so much.
(Loren) Great. Thank you so much, Michelle.
Now, I am going to hand it over to Chris Walas,
the Managing Project Director
in the Clinical Department of Quality Measurement,
and she is going to talk about our standardized measures.
Chris, I'll hand it over to you.
(Chris) Great. Thank you.
Thanks, everyone, for joining us today.
As she said, I'm Chris Walas.
I'm the Managing Project Director of our Clinical Team
in the Department of Quality Measurement.
Our team is responsible for the development and maintenance
of our chart extract and measures
as well as being the clinical consultant for eCQM Team.
Next slide.
Today, I'm going to talk about the ACPC eligibility requirements and measures.
Next slide.
I'm going to touch and highlight on the measure criteria
within the certification process.
The Advanced Certification in Perinatal Care
has new eligibility requirements.
These requirements are provided in detail in the certification manual.
This is more of a high-level overview,
but there are more details in the manual.
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 collecting aggregate performance rates
to meet threshold criteria on all applicable measures.
We'll discuss this more in detail soon.
The Perinatal Care measures specification are publicly available
and are 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,
which include PC-05, PC-02...
PC-01, PC-02, PC-05, and PC-06
and use it for ongoing Performance Improvement efforts.
At least four months of the measure data
must be available at the initial certification review,
and then for recertification, 24 months of data is required.
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 or enter performance rates into the application
must be available
at the time of the initial certification on-site review.
For recertification, organizations must continue to meet threshold criteria
for applicable measures
using the most recent 12 months of data available
to calculate those aggregate performance rates
and update their application.
Next slide.
Certified organizations will manually report
the Perinatal Care Measures to The Joint Commission
via CMIP.
Monthly aggregate values for each measure
will be reported quarterly
and are due no later than three months following the end of the calendar quarter.
Certified organizations must also meet threshold criteria
for PC-02 and PC-06 Severe Rate
at the time of initial certification and recertification.
These performance rates will be reported in the eAPP during initial application
and then updated upon recertification.
Next slide.
Let's look at measure thresholds for initial certification.
Organizations must meet the threshold criteria
on aggregate performance rates
for both PC-02 and PC-06 Severe Rate.
The organization must submit the sum of numerators
and sum of denominator into eAPP
using 4 to 12 months of the most recent data available
for PC-02 and PC-06.1,
which is that severe rate category.
The eAPP will perform the calculation
to provide the organization the aggregate performance rate,
which must meet the following threshold criteria:
The 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 complications
per 1,000 live births.
The aggregate rate for this is multiplied by 1,000 in the calculation and eAPP
because PC-06 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 I mentioned before, in your eAPP,
the sum of the numerators and denominators will be entered,
and then the calculation will be done automatically for you.
An alert will be provided to contact the Account Executive
if the denominator is less than 30
or a performance rate is above the threshold criteria.
Account Executives will confirm in eAPP that requirements are met
prior to scheduling the on-site review.
Next slide.
Now, we will look at measures in the review process for ACPC.
For the initial certification,
the organization will submit their data for performance rates into eAPP,
and the test on tab three,
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 must be provided at the initial on-site review
for validation.
If an organization does not meet denominator or threshold criteria,
they will not be able to save and submit their application.
The organization would then have two options
to either withdraw their application
or push out the ready date just to 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 review.
Initially, organizations can use 4 to 12 months of data
to calculate their performance rates.
Some organizations already collect on the measures
and may have 12 months of data available,
but 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 a total of 30 denominator cases
and meet the threshold criteria:
four months matches the amount of data required
for all Perinatal Care measures collected in CMIP,
which also needs to be provided
at the on-site review for the initial certification.
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 that they are aware of the threshold requirements
for recertification eligibility
and what their current threshold levels are.
It's important for the organization to understand
what the rates and their trends are
to ensure that they will meet 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
to the most recent 12 months of data in eAPP.
The rates will be calculated in eAPP,
and the same eligibility requirements apply for recertification.
Detailed performance improvement requirements
are found in the PI chapter of the ACP manual.
Next slide.
Trend Reports in CMIP are available for certified organizations
and will provide the organizations
with their numerator and denominator cases.
We're also developing a PC Dashboard
that will be available in The Joint Commission extranet site
for ACPC-certified organizations.
Accelerate PI reports will be available to provide aggregate rates
for rolling 12 months of data
as well as additional visual graphs and charts for the PC data.
When enough data is available,
comparison data will also be available
at state and national levels on this dashboard.
I'll turn it over to Loren. Thank you.
(Loren) Great. Thank you so much, Chris.
Before I jump into my piece,
I just want to thank all of our presenters that we've had so far.
They've been instrumental
in the development and launch of this new certification.
All of the hard work that you guys have put
into this launch and into the certification,
we are so appreciative.
Thank you, everyone.
Now, I am going to jump in
and talk about the certification and application process.
My name is Loren Salter,
and I am one of the Associate Directors of Hospitals Certification
here at The Joint Commission.
All right, if you are sitting there thinking
that you'd like to start this certification journey,
but you're not sure where to begin,
that is where I come in.
We have a team of individuals just like myself
who are there to help you throughout the certification process.
It is our job to provide you with the necessary resources
that you need during the certification process
and serve as a point of contact if you have questions along the way.
You can reach out to the email address that's provided on the screen,
which is certification@JointCommission.org
to be connected with your local Associate Director.
You'll want to get a copy of the standards,
and our Business Development team
can set you up with a free 90-day trial to the online standards
known as E-dition.
You'll then want to perform a gap analysis
to see how your program currently compares to the standards.
If you need assistance walking through the standards,
you can ask your Associate Director for help.
Should you need help interpreting a specific standard,
you can also reach out to our Standards Interpretation Group,
and they'll be able to provide you with a written response
on your compliance with the standards
or just offer concrete clarification on the standard in question.
This resource can be found on the Standards tab of our website.
In order to prepare for your application process,
you will want to identify your Clinical Practice Guidelines.
Providing clinical care consistent with evidence-based medicine
is at the heart of Joint Commission certifications.
Our reviewers will be looking to see
that your chosen Clinical Practice Guidelines
are integrated into your program and consistently being utilized.
The performance measures
for the Advanced Certification in Perinatal Care are standardized.
These are the measures that Chris just discussed during her presentation.
You will share four months worth of data from those defined measures
when the reviewers are on-site for the initial review.
After becoming certified,
you'll monitor this data on a monthly basis
and report the data
through The Joint Commission Connect Portal on a quarterly basis.
The final step to preparing for the application
is to complete the Performance Improvement Plan.
This is a series of five questions that are related
to your performance improvement initiatives in your program.
Our Business Development staff
can provide you with the template for these questions
so you can complete them before even getting into the application.
The application is done online
through The Joint Commission Connect Portal.
Your Business Development staff can assist you through this process.
We ask that your organization to make your online application
about four to six months
before you want that on-site review to occur.
since this would be an initial review,
you will get a 30-day advance notice of when the on-site review will occur.
Like Michelle mentioned, it will be a two-day review.
Let's talk about the application.
Our team of associate directors are here
to assist you through the application process,
and you will complete and submit the E-app
through The Joint Commission Connect portal.
As part of the application process,
you'll be required to report your program volumes
to ensure you are meeting the eligibility criteria
of 40 deliveries per year.
We will also ask for your ready date for the initial on-site review.
As I mentioned earlier,
you will want to submit your application
about four to six months before that ready date.
Since this would be an initial review,
you would get a 30-day advance notice
of when that review is going to take place.
As part of the application process,
you will also complete and submit the CMIP.
The CMIP--
this is where you cite your chosen Clinical Practice Guidelines,
and you'll answer those performance improvement plan questions.
I do recommend reaching out to your Certification Associate Director
for those resources available to help you through those pieces.
The performance rates must be submitted in the E-app
using 4 to 12 months of the most recent data available
for PC-02 and PC-06 Severe Rate
and meet the threshold criteria.
You will enter in the numerators and the denominators,
and the aggregate performance rate will automatically be calculated for you.
For those of you who are not familiar,
Connect is an online secure portal for information sharing
from your organization to The Joint Commission.
This is what the Connect portal looks like
whenever you sign on and how you will start the application.
If you do not have access to Connect,
your Quality Team can provide you with access
and create a username and password for you.
There are a lot of resources that are available on Connect.
Communications that take place,
the application, data entry is done on there.
If you decide to pursue certification and you don't have access to Connect,
I recommend reaching out to your Quality Team to get that started.
Your associate director will help you through the application process
to ensure that everything is complete
before you actually even submit the application.
We are here to help you every step of the way.
With the launch of this certification just around the corner,
we have a preapplication available
for those organizations who would like to be certified
in the first few months of 2023.
The preapplication will ask some general questions
about your facility,
confirm your eligibility for the certification,
and get the ball rolling before the official application
that's launched on January 1st.
If your organization would like to have an on-site review
within the first three months of the year,
I highly recommend filling out the preapplication.
One of our Associate Directors can walk you through those next steps.
The preapplication available...
It's available on our website
on the ACPC certification landing page,
and if you need help finding it,
you can reach out to your Associate Director for help.
I want to just wrap up here
before we jump into the Q&A session
and just say
as individuals in the perinatal community,
we need to fight for our moms,
and we need to advocate for their health,
everything from Prenatal Care all the way through Postpartum Care.
There were a lot of statistics that were presented today
around maternal health.
I don't want us to sit here and say,
"This is the status quo. This is the norm."
Why does this have to be the norm?
There are maternal deaths that are preventable.
What can we do?
I think certification is a great first step.
Today, you learned
about our new Advanced Certification in Perinatal Care
and how it can be a tool that your organization can use
to help improve outcomes
related to maternal morbidity and mortality.
I want to thank all of you for jumping on today
and for taking the initiative and advocating for moms all across the US.
We need to make a change, and this change can start today,
and it can start with all of you.
Thank you, again, everyone, for jumping on today.
If you are interested in pursuing
the Advanced Certification for Perinatal Care,
please reach out to the certification mailbox
that's listed here on the screen.
We also have a phone number that you can call as well
to be connected with your local Associate Director.
Now, we've actually finished up a little bit early,
which is great because I've been seeing a bunch of questions rolling in.
What I'm going to do,
I'm going to pull up my questions here,
and we will start the Q&A session.
All right.
First question here.
This is going to be for Michelle.
"How many days is the review?"
(Michelle) The review will be two days.
(Loren) How many reviewers?
(Michelle) One to two, depending on the breadth of the site.
(Loren) Okay.
Then another question here.
"What is the cost of the certification?"
I'll answer this one.
I recommend reaching out to your local Associate Director
or the certification@JointCommission.org
and we can provide you with the pricing structure
and what the pricing is.
The next question, I'll also answer here:
"When can we apply for this certification?"
The certification launches officially January 1st of 2023.
The application will be available through the Connect portal on January 1st,
but we do have a preapplication process that's available right now.
Like I said, it's on our ACPC landing page,
or you can contact your local Associate Director
to get a copy of that.
This question will be for Michelle.
"Will the NICU be reviewed,
and if so,
can you explain in more detail how this will fit into the review?"
(Michelle) We typically go into the NICU.
What we evaluate there
is the infants that started out in the nursery,
and then the care was escalated up into the NICU,
and we would evaluate those policies, procedures,
how you communicate,
how does the team make determinations,
and what are the criteria for admission into the NICU.
(Loren) Great. Thank you so much, Michelle.
The next question here is one I'll answer.
It says, "How do we get a copy of the standards?"
You can reach out to your local Associate Director
to get a copy of E-dition.
There should also be a Contact Me button,
I believe, on the ACPC landing page,
which we'll also filter into that certification mailbox,
or you can reach out to that certification mailbox,
so we've got a couple of different avenues of how you can get that,
but it will be available through E-dition, which is our online standards manual.
All right, this next question,
this is going to be for Chris Walas for measures:
"What are the threshold for the measures PC-02 and PC-06?"
(Chris) Sure; the threshold for PC-02, Cesarean Birth Rate, is
less than or equal to 30% for the C-section rate,
and for PC-06,
that is the Unexpected Complication in Term Newborn,
a severe rate of less than 50 complication per 1,000 live births.
(Loren) Great. Thank you so much.
All right. Let me see here.
This one's a little bit of a longer question.
Chris, this is for you again.
It says, "I am an AVP for a health system
that has 60 hospitals in mainly rural communities.
For those hospitals with less than 300 annual births,
what will the data requirements be with PC-02 and PC-06?
They collect the data, but are not required to report
since it's not statistically significant."
(Chris) That's where the 30 denominator cases comes in.
We're not as concerned about how many deliveries per year.
As long as your performance measurement rates
have a denominator case greater than 30 cases,
then you would be able to submit the performance rates
and have those thresholds apply.
(Loren) Great. Thank you so much.
I think this one's going to be for Jen Anderson.
This says, "I'm curious
if or how The Joint Commission engage communities
most burdened by inequities to weigh in,
such as Black women, or birthing folks, etc?"
(Jen) Can you read that again? I'm sorry, you were breaking up.
(Loren) Yes, I'm sorry.
It says, "I'm curious
if or how The Joint Commission engage communities
most burdened by inequities to weigh in,
such as Black women, or birthing folks, Asian women, etc?"
(Jen) In our Technical Advisory Panel,
we engaged a certified nurse midwife group,
and we had a representative from New York City
who had a really strong midwife group practice
that was out of one of the hospitals in New York City.
She's really involved and really vocal
in the development of the requirements.
Usually we'll send our requirements out for field review.
It's open to anybody.
We did receive a lot of feedback from that population,
and then we incorporated that in.
(Loren) Thanks so much, Jen.
I can answer this question.
It says, "When will PNC certification be phased out?"
This new certification launches on January 1st of 2023.
That is when the new certification will take effect.
All of the organizations who are currently perinatal-certified
have been contacted by their Account Executives
as far as what those next steps would look like
as far as maintaining the certification
or transitioning to the new ACPC certification.
Like I said, the new certification will launch January 1st.
Jen, this question is going to be for you.
"Universal screening, as in urine test:
every patient or have a screening tool
to ask questions related to drug and alcohol use?"
(Jen) We leave that up to the organization.
The intent is behind a screening tool
not necessarily a urine drug screen on every patient,
but we leave that up to the organization to make that determination,
but it's meant to be more of a tool.
(Loren) Great, and this one goes along with that, as far as screening.
It says, "How would the screening and treatment of substance use
in the mother be assessed for certification
in states where positive screening for substance abuse during pregnancy
is criminalized?"
(Jen) That's a good question.
The requirements that we have
are that it's universal screening on every patient.
I don't think we would distinguish anything different.
In states where it could be criminalized,
we would still expect that we would be screening all patients.
(Loren) Okay. Thanks, Jen.
All right. Okay, this one's going to be for Michelle.
"For the chart abstraction,
are there specific types of patients
or conditions and outcomes that would be audited,
or is it random,
and what metrics are being used to assess the chart abstractions?"
(Michelle) When we go in,
some of what we do is look at available patients
on the units on the day,
or the following day of the two days that we're there.
We'd like to review patients that are in labor,
perhaps someone that's being induced,
a C-section,
a fetal demise.
We like to do an overarching sample of what is available in there.
Oftentimes...
For instance, if we wanted to look at mag patient,
especially given that hypertension is one of the elements
that has a weighed in...
that is important for us to be looking at.
If there isn't a mag patient that is there
the initial day that we do the review,
we will come back the next day and look for a mag patient,
but we'll leave that first day and say,
"In the event that there isn't a mag patient
that comes in overnight
or that we could evaluate tomorrow,
we would do a close-chart review
and give the institution time, the night,
to look to determine what other patients
they might be able to provide for us the following day.
(Loren) Great. Thank you so much, Michelle.
All right, I think this one's going to for Jen.
It says that "You have said every pregnant and postpartum patient
will be assessed for mental health disorders.
Our facility currently completes a suicide risk assessment
on 100% of patients.
There are plans in the works to change this practice
to align with the TJC National Patient Safety Goal
related to suicide risk assessment,
and based on this,
our facility is moving to assessing patients 12 years and older
who present with behavioral health concerns
as their chief complaint.
This will effectively eliminate
our assessment of 100% of patients for suicide.
How will this impact the recommendation for this metric?"
(Jen) This would go above and beyond suicide risks.
Do we have patients who have a history of postpartum depression,
anxiety,
any other sort of mental health condition?
So this would actually be above and beyond the suicide risk tool
that's currently being used for other populations.
This would be in addition to that.
(Loren) Great.
This one is going to be for Chris.
It says, "Is there a document that we can access
that lists all of the measurement requirements?"
(Chris) The certification manual
does have all of the requirements surrounding measurements and thresholds,
and then on The Joint Commission website,
our manual specifications are there,
and they list all of the Perinatal Care measures
and all of the specification requirements.
(Loren) Chris, this is another question for you.
It says, "For the initial certification and PC data,
can we use more than four months?
If so, how far back can we go,
and can we choose how many months of data to use?"
(Chris) For the initial certification, you can use 4 to 12 months of data.
If you have a full 12 months of data,
and you would want to use
the most recent data that you have available
that you've collected on,
you are able to use that for the initial certification.
Four months is allowable, again,
so that organizations that do meet all the requirements
with four months of data,
but are new to the measures and haven't collected the full months,
they don't have to wait a full year before applying for the certification.
At recertification, though,
you will be collecting on these measures for the full 24 months,
so you will use the most recent 12 months of data for recertification.
(Loren) Thank you.
All right, this next question I will answer.
It says, "Will we get this presentation?"
Yes, if you've registered for the event, you will get a copy of the slides
sent to your email that you registered with,
so you will get a copy of the slides.
Another question about cost of the certification,
and it says, "Can you confirm that it's every two years?"
The cost, again, please reach out to your local Associate Director
or the certification@JointCommission.org
to be connected with your local Associate Director.
We'll review the cost, the fee schedule with you,
what that looks like.
Yes, certification is a two-year cycle,
so every two years, you would have an on-site review.
(Loren) All right, Jen, I believe this question is for you.
It says, "For social determinants of health,
is there a specific number of items we should focus on?
For example, transportation, access to care,
food insecurity, etc?
Do we have to screen for all of this,
or can we choose which ones we have to focus on?"
We would really like you to do that deep dive into your community
and determine what is an issue for your specific patient population.
We don't say you have to assess for X, Y, and Z.
It really is up to your organization,
and it should be based on your community assessment.
We do not have specific requirements,
except that you are doing it.
That's all.
(Loren) Okay.
(Michelle) Can I add something, Loren?
(Loren) Yes! Go ahead.
(Michelle) When we come out in our on-site,
we do often ask for the most recent community assessment
so that at a break, we can review it,
so when we're doing our in-person assessment,
we can determine
whether or not the needs that popped up in their community assessment
are those that are standardized and being followed through
in the policies and the practice of the organization.
(Loren) Thank you so much for adding that in, Michelle.
(Michelle) Great.
(Loren) All right, this next question I'll answer here.
It says, "We filled out the preapplication.
When is the full E-Application due for submission?"
The E-Application will be due...
Guess that's up to you whenever you want to submit it,
but it will be available come January 1st.
If you've already submitted your preapplication,
your local Associate Director will be reaching out to you sometime in December
to potentially schedule a time to walk through that application with you
to ensure that you've completed the application,
and that it's been received on our end.
You'll get some communications in the upcoming months
from your Associate Director,
but it will be available January 1st for you to fill out.
Michelle, this question is for you.
It's asking, "What perinatal units are included in the on-site review?"
(Michelle) Any unit that is in the hospital--
We will do triage
if it's separate aside from Labor and Delivery.
We do Labor and Delivery.
If there's an Antipartum,
you could expect that we go up and trace the patient on antipartum.
We would do Mother/Baby
and the NICU.
Typically, institutions still have a nursery.
We have a discussion about what does the nursery used for--
things like that--
but if an organization has every one of those units,
then we would do a touchpoint in each one of them.
(Loren) Great. Thank you, Michelle.
This question I'll answer here.
It says, "Does your hospital need to be perinatal certified first
before we can apply for the Advanced Perinatal Certification?"
The answer is no.
Your hospital does not need to be perinatal-certified
before you can jump into this new certification.
It's available to any organization
who is looking to pursue the certification.
It's not a prerequisite for pursuing ACPC.
(Loren) All right, Jen, this question is for you.
It says, "For ACPC,
one..." Let's see here.
ACPC... I'm sorry.
PI.01 EP 1
stratifying data by race,
ethnicity, and language.
What are the aims of this? Is it just a collection of data?
Is it for performance improvement? What's the goal behind that?"
(Jen) I would say all of the above
to assess if your organization has any sort of disparities
that you can address based on that stratification.
It is the data collection.
It's doing that deep dive to determine
if there are differences based on any of those criteria
and then making Performance Improvement Plans
behind them
if they do exist.
(Loren) Great. Thanks, Jen.
(Jen) You're welcome.
(Loren) This may just be kind of a conversation.
I think anyone who wants to jump in and can help answer this...
It says, "Can you discuss how you anticipate this
addressing the serious disparities for Black mothers?"
(Jen) I think the focus on that PI question that was just asked,
I think, we have to identify
in our own organization and in our community
if we have disparities and then what can we do about them.
I think that's just the first step
in the grand scheme of the work that we need to do.
These are supposed to be organizations that are the top performers.
Hopefully, other work is happening behind the scenes
in regards to those patient populations,
but that PI question really is the first step.
I don't know if anyone else wants to address that as well
because we don't even know if we have an issue
if we don't look.
(Michelle) I can give an example, or two examples,
if that would be helpful.
Recently, on a site visit,
we were out visiting an organization that had a large Mixteco population,
and that is a population of Mexican individuals
that had emigrated into their community.
They, over time, realized
that Spanish interpreters and the Spanish language
didn't address their needs,
so they, as an organization, recruited 21 individuals
that now staff their institution 24/7
to provide that service
because apparently, they don't have a written language,
so everything is communicated orally.
That would be an example
of how, within a community, someone determined what the need was
and then extrapolated how, as an organization,
they could embrace that need
and make the outcome for that group of individuals improved.
(Loren) Thank you so much.
This question is going to be for Chris.
"Is there any additional information on PC-07 for ACPC,
and how it may be addressed during a review or in the future?"
(Chris) Definitely, PC-07 is an eCQM-only.
It is an optional measure for accredited organizations
and will be an optional measure for CMS.
Since it is new, it is not required yet in ACPC.
However,
a lot of the standards, hypertension, hemorrhage-- things like that--
will be, hopefully, lowering SMM and mortality rates.
However, definitely, in the future, it is something that,
as the measure developes,
could potentially be a requirement in the future for ACPC.
But definitely, it's already out there
for optional submission to Joint Commission
and will be optional starting in January for CMS.
(Loren) Great. Thanks, Chris.
This question here says,
"My facility is deciding
between the Maternal Levels of Care Verification
or ACPC certification.
Are they separate surveys?
Can you combine them?"
I'll answer this.
I would recommend reaching out to your Associate Director
to provide you with the appropriate resources
for you guys to make that decision.
They have a separate set of standards, different requirements.
I would recommend reaching out to get those requirements,
so you could do an in-depth gap analysis
to see what was the best fit for your facility.
Your Associate Director can go through the pricing for each of those as well
and talk through what that process looks like.
(Loren) All right, Chris, this one's going to be for you for measures.
"How many months of meeting the goal for PC-02 and PC-06
do we need to demonstrate?
Is it so many months consecutively, or so many within one year?"
(Chris) We use an aggregate performance rate,
so you'll be adding your monthly numerator and denominator cases
to get that aggregate rate.
This way, if you have one month
where you're a little bit above the threshold,
we're looking at that total aggregate rate to be below the threshold criteria.
That's why the 12 months that would be adding together
your numerators and denominators,
not looking at one specific month.
Whether you're above or below that threshold,
you want your aggregate rates to be below that threshold,
so it's important to look at your trends and your monthly rates,
but when it comes to meeting the threshold requirement,
it's that aggregate performance rate that we're looking at.
(Loren) Okay, thanks so much, Chris.
This question here,
it says, "As this is a new survey,
how soon after January 1st
will The Joint Commission start surveying organizations?"
I can answer the first part of this.
This is where the preapplication process will come into play.
If there's an organization
who's interested in being reviewed within the first quarter,
first couple of months of the year,
I recommend filling out the preapplication available online.
You can speak with your Associate Director,
and they can go through that time frame with you,
but I don't know, Michelle, do you happen to know
if we're going to be doing some reviews in January?
(Michelle) I haven't talked to the individual, like my scheduler,
to determine that.
I think it really depends on interests
and whether or not individuals are putting forth the preapplication.
As you had indicated, they can.
We're ready to go.
If there are people that are interested,
then get the queue.
(Loren) Great. Thanks.
Okay, it says,
"Will a drug screen be required starting 2023 for mothers?
Our facility does not currently perform this."
I think, Jen, that might be for you.
(Jen) Not necessarily a screen, just screening tool.
It would only be for ACPC.
It's not a part of our normal hospital accreditation requirements.
(Loren) This one, I will answer here.
It says, 'If we are currently certified with PNC,
will this be considered an initial visit for ACPC?"
The answer is yes.
This will be treated as a new initial certification,
so you guys would get that 30-day advance notice
of when the on-site review is going to take place.
Okay, this one... Chris, this is for you.
This organization's in California,
and they use CMQCC,
Maternal Data Center for ongoing quality care.
Do you know if these statistics can be used
for the application for certification?
(Chris) I know that the Maternal Data Center
and CMQCC does collect these measures.
However,
they will need to be separately submitted to The Joint Commission.
so your measure rates you would submit to CMQCC,
and then the certified organization would need to submit
their measure rates in CMIP,
and in the eAPP application,
you would need to manually enter some of the numerators and denominators
to calculate the rates.
Likely, it's the same information that you're using.
However, you do need to submitted separately to The Joint Commission.
(Loren) I don't know, Jen, if you have this.
It says, "Do we have a resource for a community assessment
that we can use to determine our gaps?"
(Jen) To do the community assessment is what the question is for?
It's definitely something that we can look into.
I don't know if, Michelle, have you seen anything on-site
with good community assessment tools?
We more or less looked at
the health-related social needs screening tools,
not necessarily the big community assessment tool,
but that's definitely something that we can look into
and create some sort of easy access go-to for resources,
but that's not something I have as of today.
(Michelle) My recommendation would be
that if the hospital that posed the question
or any others that are looking at refining
or creating a community needs assessment
is perhaps using any quality partnerships,
either within the state or within the community
to see how others have been evaluating it.
I know that, typically, out of California,
there's some really robust data that has been extrapolated
down to they even look at their community makeup
and literacy within the community
to see whether or not that would be a need of the patients
that are coming to their organization.
That's the most refined data that I've ever seen.
(Loren) Great. Thank you.
Michelle, this one is also going to be for you.
It's talking about Clinical Practice Guidelines.
"Can you elaborate
as far as what you would be looking for during the on-site review
as it relates to Clinical Practice Guidelines."
(Michelle) For sure.
All of our governing bodies
often put out position statements for...
The most recent update that I'm thinking of is jaundice.
The American Academy of Pediatrics,
probably, five weeks ago, put out a statement on it.
I think that what we look to is
is the organization looking at their policies and procedures
and embracing the latest evidence-based practice
or aims or standards
that have been initiated from your governing body.
We look how those have been embedded in your policies and practices
and then whether or not your team on the frontline has embraced them
and is consistent about using that standardization methodology
to attack the patient population.
Does that make sense?
- Okay. - (Loren) Yes.
(Loren) Great. Thank you so much.
All right, we've got a couple more questions here.
This one looks like it's expanding on a previous question and discussion
around identifying whether there is a racial or ethnic disparity or not.
This question asks,
"Is there a goal of The Joint Commission
and ACPC program
to reach out to national groups who already have this data
and have identified that there is a disparity nationwide
and who already are doing the work to address these disparities?"
I think this might just be elaborating on the discussion
a little bit more before.
I don't know if there's anything else to add in there.
(Jen) Yeah, I know as far as disparities,
we're looking for organizations
to really get into their specific community.
Obviously, if we're incorporating evidence-based practice guidelines
into our practices, our daily practices or policies and procedures,
we can look into those national organizations
for that sort of work,
but when it comes to really improving outcomes within our patient population,
that's what we're really hoping for when we ask organizations
to do that deep dive into their potential disparities
within their patient population.
- (Loren) Great. - (Michelle) One example...
One example in the field will be
when we look at breastfeeding rates
and the exclusive practice within the institutions,
nationally,
it's believed that Mexican moms
often do breast and bottle,
but what I suggest to organizations is
sometimes we come with a bias--
nationally, we might think that this is the trend,
we should then embrace that and do it in our community--
but your community could show something drastically different,
and your hypothesis may be totally different
when you do the deep dive.
To Jen's point,
that's why I think we should really...
If we're really trying to improve outcomes within our community,
then we need to look at our communities
to figure out what we can implement
that would impact them positively.
(Loren) Yes, thank you so much, Michelle.
This is the last question that we have here.
Michelle, this one's for you.
"How do Ambulatory OB clinics fit into the certification,
and will they be reviewed?"
(Michelle) To date, we have not gone...
I can't say we haven't gone into a clinic.
If people have really robust clinics,
we may do a walk-through during our tour
to talk about how that flow impacts them in the organization,
but we don't do a specific tracer in an outpatient facility.
We're really focusing on the inpatient,
but if we have time and the organization wants to share that with us,
then we try to make an effort to accommodate.
(Loren) Thank you so much, Michelle.
There's actually another question that just rolled in here,
and this says, "In Texas,
this would be in addition to our maternal designation, correct?"
The answer is yes.
The ACPC certification is a voluntary certification
that you could also pursue at your facility.
All right, I'll give it just another minute or so
to see if there's any other questions that roll in here.
All right, it looks like we have answered everyone's questions.
Thank you, again, everyone, for jumping on today,
and thank you, again, to all of our presenters.
As a quick recap,
everyone will get a copy of these slides and the recording sent
within the next couple of days.
If you have any other questions about the certification,
or you're interested in the preapplication process,
please reach out to certification@JointCommission.org
to be connected with your local Associate Director.
With that, I want to just say thank you to everyone for jumping on.
I hope that you guys had a great informational session today
and I look forward to working with everyone.
Take care.
(Jen) Thank you.