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Recently, Northside Hospital in Atlanta, Georgia became the first in the nation to complete The Joint Commission’s Maternal Levels of Care Verification. Developed in collaboration with the American College of Obstetricians and Gynecologists (ACOG), Maternal Levels of Care Verification aims to reduce maternal morbidity and mortality by encouraging the growth and evolution of systems that help standardize perinatal regionalization and risk appropriate maternal care.

Participating interviewees included:

  • Janis Dubow, Vice President of Patient Care and Chief Nursing Officer, Northside Hospital System
  • Kelly Inoue, Operations Director of Women’s Services, Northside Hospital
  • Ellen Evans, Director of Accreditation and Patient Safety, Northside Hospital System
,,Maternal Levels of Care Verification was a chance to confirm and demonstrate the high level of care we provide our patients.,,

Kelly Inoue - Operations Director of Women’s Services - Northside Hospital

Q: What kind of provider organization is Northside Hospital?

Janis Dubow: Northside Hospital is one of Georgia’s leading health care systems, with five acute-care hospitals and more than 275 outpatient locations across the state. Our 621-bed Atlanta campus delivered more than 15,800 babies last year, more than any other single U.S. hospital, giving us unmatched experience with high-risk, complicated pregnancies.

Q: Why did Northside Hospital decide to pursue Maternal Levels of Care Verification?

Janis Dubow: The Georgia Department of Public Health wanted to improve the care for moms and babies in Georgia, and we wanted to be a part of that. Members from Northside were part of the original group tasked with defining the maternal standards. I think aiming for verification was a natural outgrowth of that process. Once verification was available, we already had the partnership between Georgia and The Joint Commission, so we were ready.

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Q: How did Northside Hospital prepare for Maternal Levels of Care Verification?


Kelly Inoue: Northside Hospital has a long history of partnering with community providers and specialists to ensure that we’re providing the highest levels of care. So, we looked at the process of preparing for verification as just another opportunity to organize the community at large and our team in pursuit of a common goal. Maternal Levels of Care Verification was a chance to demonstrate and confirm the high level of care we provide our patients.
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Q: Did you take any specific steps prior to the verification process?


Ellen Evans: Because Northside Hospital has been a Joint Commission-accredited hospital for almost 30 years, we had a good idea of the steps we needed to take to prepare for verification.

When the new standards came out, we read through them thoroughly, and then conducted a gap analysis to map out our priorities. From the gap analysis, we were able to identify tweaks and improvements we needed to make to meet the standards. Another important component was ensuring that Northside staff had a comprehensive understanding of and could articulate the care they provide.

Prior to verification we started doing weekly tracers, and then we increased our frequency to make sure that we had consistent practices and processes. We take pride in our continuous readiness efforts.

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Q: What was the experience like working with The Joint Commission?


Ellen Evans: We started out by having a couple of conference calls with our Joint Commission representative to talk through the process. Once we completed the formal application, our account representative called to verify the numbers and to make sure that we were ready. 

Our reviewer was experienced in maternal care and knowledgeable about the whole continuum of care we provide. The experience was actually fun! It’s a little bit of a different process because she was there to verify that we were meeting standards, rather than to do a traditional survey.

Our reviewer was very professional and kept us apprised of what she was thinking throughout the process. Our team was very open, honest and transparent with her. I thought it was a great two days. She was really clear about what she wanted to see and what she observed. And, as you can imagine, delivering more than 15,800 babies a year — we had quite a variety to show her!

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Q: Given the challenges many states have experienced with maternal morbidity and mortality, how do you think this verification program will help overall?


Janis Dubow: We’re hoping that by showing how this process worked well for us, other hospitals will follow a similar approach and feel comfortable seeking verification. The goal is to motivate more hospitals to identify and meet whatever their appropriate level of care would be. Through the verification process we’re able to have a positive impact on outcomes for both our moms and babies.

Q: What are some of the outcomes that resulted from the verification process?


Kelly Inoue: We have noticed a sense of pride in the work that our team does. Ultimately, this helps us with quality measures, with retention and with community outreach. This verification demonstrates to the community that we are leaders in maternal health.

Janis Dubow: The whole process was very interactive and collaborative, incorporating the entire team. The format of the discussion was truly interdisciplinary, and that really helped to get everybody on the same page. The verification process highlighted how the entire team worked together and helped to standardize the care that we provide.

Q: What advice would you give an organization who might be thinking about pursuing verification?


Ellen Evans: The key is to sit down and read the standards and then complete your own gap analysis. Remind yourself that you are doing these things, you are providing a high level of care and you can do this.

Q: What kind of impact do you think this process will have on the community, in terms of the care that you provide?

Janis Dubow: It helps ensure that people in the community have a clear understanding of all the services that are available to them. One thing that the community will hopefully understand is that we can help them with their pregnancy whether it is low risk or high risk. We want our community to feel totally confident that we can help mothers through all parts of their pregnancy journeys.

Discover more about Joint Commission Maternal Levels of Care Verification.

Learn more Find out more on maternal levels of care verification