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The Joint Commission Releases R3 Report on New Maternal Infectious Disease Requirements for Hospitals

Report provides in-depth rationale and evidence for new requirements

January 11, 2018
By: Katie Looze Bronk, Media Relations Specialist

(OAKBROOK TERRACE, Illinois – January 10, 2018) – HIV and other transmittable diseases can have serious consequences for both a woman and her baby. While some problems may be seen at birth, others may not be noticeable until days, weeks or months later. 

To improve the identification of mothers upon admission to labor and delivery who are at risk for transmitting certain infectious diseases to their newborns, The Joint Commission is implementing three new elements of performance (EPs), effective July 1, 2018. The EPs are applicable to all Joint Commission accredited hospitals and critical access hospitals that provide obstetric services, specifically labor and delivery, to ensure that the mother and/or newborn is promptly treated to prevent harm. 

To help hospitals better understand and comply with these requirements, The Joint Commission has released a new R3 Report. The report provides in-depth rationale, references and evidence that The Joint Commission employed in the development of the EPs.

The EPs outline specific actions, processes or structures that must be implemented to achieve the goal of a standard and specifically address HIV, hepatitis B, group B streptococcus and syphilis: 

  • Upon admission to labor and delivery, the mother’s status of the above diseases is documented in the mother’s medical record.

  • If the mother had no prenatal care or the disease status is unknown, testing for the above diseases is performed and the results documented in the mother’s medical record.

  • If the mother tests positive for any of the above diseases when tested in labor and delivery, that information is also documented in the newborn’s medical record after delivery.

“The requirements will help improve maternal and neonatal health in Joint Commission accredited hospitals and critical access hospitals across the country,” says Kathy Clark, MSN, RN, associate project director specialist, Division of Health Care Quality Evaluation, The Joint Commission. “If left undiagnosed or untreated, infectious diseases can be extremely dangerous and even life-threatening, so it is critical that testing and treatment for both the woman and baby is completed according to clinical practice guidelines.”

The new EPs were developed after an extensive literature review; meetings with stakeholder groups, including the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP); and a public field review. A standards review panel also reviewed the draft requirements for maternal status documentations. 

The R3 Report is available on The Joint Commission website. It may be reproduced if credited to The Joint Commission. 

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The Joint Commission
Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 21,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at www.jointcommission.org.

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