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The following is an excerpt from the Q&A following our Insights webinar, “Meeting The Joint Commission’s New Perinatal Safety Standards” hosted by Bud Pate and Lisa Eddy, Senior Consultants with The Greeley Company. To watch the free on-demand recording of the webinar, please click here.

Q: Does the criteria for cases to be reviewed need to be spelled out in a policy?

A: No. A policy statement is not required. There are two requirements for case review the new perinatal safety standards.

(Hemorrhage) PC.06.01.01 EP06: Review hemorrhage cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided by the hemorrhage response team during the event.

(Preeclampsia) PC.06.03.01 EP05: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.

When The Joint Commission requires an organization to produce non-medical-record documentation (e.g. a policy or procedure) to demonstrate compliance with a requirement it annotates the corresponding element of performance with a “circle D” icon. Neither of the above requirements bare the “circle D” icon so, in theory, written documentation such as a policy is not required to demonstrate compliance.

Case selection criteria must nevertheless be developed and followed.

Criteria for case selection can be built into the case review / abstraction forms. Such criteria can also documented in the database query created for records selection. (Case listings from the medical records database often have the selection criteria in the header.) However, whatever it takes to identify the cases to be reviewed should suffice to demonstrate compliance during survey.

The Council on Patient Safety in Women’s Health Care (safehealthcareforeverywoman.org) has sample case review sheets that address both maternal hemorrhage and birth-associated severe hypertension. Although each organization is responsible for developing its review criteria, the Council suggests, as an example,

  • Hemorrhage (PC.06.01.01 EP06) Pregnant, peripartum or postpartum women receiving 4 or more units of blood or admitted to the ICU or other severe and unexpected medical event, and
  • Preeclampsia (PC.06.03.01 EP05) Severe hypertension/eclampsia cases admitted to critical care for systems issues.

It is anticipated that case review criteria will evolve over time to improve focus and sensitivity. For that reason, we believe it is best to capture these criteria on a case review sheet or similar tool rather than a policy statement since policies can take a long (long) time to modify.

A word of caution: please be able to demonstrate that the case selection criteria were developed and modified based on input by the clinicians performing the case reviews with the knowledge and approval of the clinical team responsible for the hemorrhage / preeclampsia guidelines.

About Greeley’s Compliance Consulting Division: The Greeley Company helps hospitals and health systems across the country address and solve regulatory compliance, quality, and accreditation challenges. Our consultants are experts in the field with hands-on experience working with accreditation agencies and providing actionable plans to keep organizations out of trouble. For more information on how Greeley can partner with your organization on healthcare compliance challenges, please email info@greeley.com or call 888.749.3054. 

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