New York State Department of Health

Division of Family Health requirements for the Regional Perinatal Center

As part of the Regional Perinatal redesignation process, the New York State Department of Health has defined specific responsibilities for institutions designated “Regional Perinatal Center.” These include many responsibilities present before the redesignation process, along with several important additions regarding regional QA/QI and creation of Perinatal Forums. The Department of Health has included these responsibilities into the Perinatal Data System contract. What follows is taken from the New York State Department of Health Division of Family Health requirements for the Regional Perinatal Center.

Regional Perinatal Centers responsibilities:

• Participate in quality improvement, attending level consultation, perinatal patient transfer consultation and transport, and in meeting the training and education needs of perinatal affiliate hospitals.

• Implement quality improvement activities at perinatal affiliates, including serving as the affiliate’s agent for onsite quality of care review.

• Participate in and coordinate region wide data collection, analysis, and retrieval activities among perinatal affiliate hospitals using the Statewide Perinatal Data System.

• Develop or continue the development of a Regional Perinatal Forum to strive to improve pregnancy outcomes through collaborative efforts by hospital and nonhospital representatives to increase access to perinatal care, achieve improvements and quality of perinatal care, and to address other regional public health issues related to maternal and infant health. Regional forums will be co-chaired by the RPC and a comprehensive prenatal-perinatal services network representative or another appropriate community-based representative.

The Department of Health considers RPC quality improvement activities to be its number one priority. The mandate extended to the RPC includes:

• Conducting outreach and education activities to all perinatal affiliate hospitals.

• Acting as each affiliate’s quality of care reviewer to conduct onsite review of the quality of care provided at each affiliate hospital.

• Identification of hospital specific or systemic problems affecting quality of care of designing and implementing measures to remedy these problems.

• Developing and implementing affiliation agreements with all associated hospitals in compliance with current departmental regulations and acceptable standards of perinatal care.

In addition, a letter received from the Department of Health on April 10, 2002 requested information on whether we receive and review records for newborn and obstetric patients other than those subject to mortality and morbidity reviews, whether we review pathology related to all perinatal deaths and significant surgical specimens at each affiliate, and whether we review and comment on QA/QI plans and procedures/processes at each perinatal affiliate. Some of this had been done in a less formal manner during scheduled outreach visits in recent years, but it appears that the Department of Health is asking for a more formalized system.

The New York State Department of Health is mandating a more active involvement in QA and QI activities in the region. Mechanisms have been in place in recent years for reporting of significant quality problems to the State, and for reporting of ongoing or unresolved issues between affiliate hospitals and an RPC, should such occur. What the Department of Health presently is asking is for formal reporting of the RPC’s role in QA/QI in the region. Outcomes that result in patient transfer are routinely reviewed at outreach visits. Serious adverse outcomes that do not result in transfer, such as fetal or maternal deaths at the affiliate hospital, should be reported to the RPC along with accompanying medical records, pathology, etc. These occurrences will be discussed either at the outreach visits, or if circumstances warrant, at meetings specifically convened for formal review.