Prepare for a Maternal Survey - Tips from a Program Manager Lauren Moore, BSN, RNC-OB, C-EFM Perinatal Program Manager Medical City Dallas Hospital

Things that went well: Start early Keep everything - better to have too much than not enough Pre survey is a guide to supplement designation rules TETAF support Nursing and Hospital administration support Being organized Having a plan for items you know you don’t have in place yet Multidisciplinary meeting - preparation Primary Provider (6) The primary physician or certified nurse midwife with competence in the care of pregnant patients, whose credentials have been reviewed by the MMD and is on call:    (A) shall arrive at the patient bedside within 30 minutes of an urgent request; Mid- levels: (7) Certified nurse midwives, physician assistants and nurse practitioners who provide care for maternal patients:     (A) shall operate under guidelines reviewed and approved by the MMD; and     (B) shall have a formal arrangement with a physician with obstetrics training and/or experience, and with maternal privileges who will:       (i) provide back-up and consultation;       (ii) arrive at the patient bedside within 30 minutes of an urgent request; and Back up coverage 8) An on-call schedule of providers, back-up providers, and provision for patients without a physician will be readily available to facility and maternal staff and posted on the labor and delivery unit.   (9) Ensure that physicians providing back-up coverage shall arrive at the patient bedside within 30 minutes of an urgent request. Anesthesia (A) Anesthesia personnel with training and experience in obstetric anesthesia shall be available at all times and arrive to the patient bedside within 30 minutes of an urgent request.

Things that I wish I knew: Time it takes to get required documents Work out IT issues ahead of time Prepare your helpers for record reviews Requests for Neonatal Intensive Care Unit (NICU) RN and RT competencies Physician involvement – buy in Physician competencies: - attestation statement vs actual competencies How to track quality items such as provider response times or stat procedures Before we get started, we are going to review a few important definitions out of TAC 133.202. These definitions are important to understand when addressing responses and response times required in the rule. Urgent request – requiring immediate action or attention (Identify in your program plan and policy when a physician or nurse midwife should respond to the request of the nurse) Available – relating to staff who can be contacted for consultation at all times without delay. On-site - At the facility and able to rapidly arrive at the patient bedside for urgent requests. The rules are clear and will delineate when personnel or services have to be on-site versus available. Immediately – without delay For this presentation, we are going to focus on the actual response times listed in the rule, such as 30 minute response times.

Ask us a question! Carla Rider, DNP, MBA, RNC-LRN, texasperinatalservices.org Carla Rider, DNP, MBA, RNC-LRN, TETAF Perinatal Program Director crider@tetaf.org