Becker's Clinical Quality & Infection Control

17 QUALITY IMPROVEMENT & MEASUREMENT CMS issues new hospital maternal health, safety standards: 8 things to know By Elizabeth Gregerson T o address the maternal health crisis in the U.S., CMS has issued new conditions of participation standards for hospitals that offer obstetrical services as part of its 2025 Hospital Outpatient Prospective Payment System rule shared Nov. 1. e new requirements will ensure all Medicare- and Medicaid- participating hospitals offering obstetric services are "held to a consistent standard of high-quality maternity care that protects the health and safety of pregnant, birthing and postpartum patients," according to a Nov. 1 CMS fact sheet. Here are eight things to know about the new standards: 1. Hospitals must meet the maternal health conditions to avoid termination from Medicare and Medicaid. 2. CMS is finalizing a phased implementation plan for the new requirements to address potential burdens raised during public feedback. e planned implementation will start in 2026 and occur in three phases over two years. 3. Among the new requirements for organization and staffing are: • Obstetric services be "well organized" and in line with nationally recognized stands of healthcare. Services should also be appropriately integrated with other departments in the facility. • All obstetric units be supervised by an appropriately trained individual, such as an experienced registered nurse, nurse practitioner, certified midwife, physician assistant, MD or DO. • Obstetric privileges should be granted for all providers in the unit in accordance with current hospital requirements. 4. Requirements for service delivery are: • Basic obstetric equipment be kept at the facility and readily available with respect to the facility's scope, volume and complexity of services offered. • Facilities have facility provisions and protocols for emergencies, complications and post-delivery care that are consistent with nationally recognized and evidence-based guidelines. 5. Requirements for staff training are: • Hospitals develop and ensure all obstetric staff have been trained on policies and procedures that improve the delivery of maternal care. Training must be documented and reviewed every two years. • Hospitals use findings from quality assurance and performance improvement programs to revise procedures and protocols. 6. Requirements for quality assurance and performance improvement programs are: • Hospitals use its quality assurance and performance improvement program to collect and analyze data to develop action plans to address health disparities and improve outcomes among obstetric patients. • If a maternal mortality review committee is available in a hospital's geographical region, the hospital must incorporate publically available data into its quality assurance and performance improvement program. 7. Requirements for emergency services are: • All hospitals that provide emergency services have adequate provisions and protocols to meet the needs of obstetric patients, regardless of whether the facility provides obstetric services. e provisions and protocols must be consistent with nationally recognized and evidence-based guidelines. • All emergency services staff have undergone documented training on the protocols and provisions. • Facilities have provisions set aside for obstetric emergencies. 8. Requirements for transfer protocols are: • Hospitals have policies and procedures for obstetric patient transfer. All relevant staff must be trained on the transfer policies and procedures." n Postpartum hypertension program cuts readmissions 69% By Mariah Taylor A new postpartum, at-home blood pressure monitoring program at M Health Fairview reduced postpartum readmissions due to hypertension by 69%. The program began at Minneapolis-based M Health Fairview University of Minnesota Medical Center in November 2023, according to an Oct. 14 system news release shared with Becker's. New mothers diagnosed with high blood pressure are provided with monitoring tools for six weeks after delivery. Blood pressure is taken twice daily and entered into an app connected to MyChart. Maternal-fetal medicine nurses review the patients' blood pressure readings and reach out if there are concerns. Since the program was launched, it has helped more than 367 patients. Early results showed that 88% of participating patients reported a blood pressure reading within the first 72 hours of discharge and readmissions were reduced by 69%. "This is a great start, and we're optimistic about the future of this program," Bethany Sabol, MD, who created and runs the program, said in the release. "While it's currently available only at the M Health Fairview University of Minnesota Medical Center, we are making plans to expand it across our entire system starting in 2025." n

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