Surveyors Are Headed to Labor and Delivery – Are We Ready?




Rob Durkee, MHA, RN, FACHE, Accreditation Advisor

Each year in the U.S., approximately 700 women die as a result of pregnancy or pregnancy-related complications, according to a report recently published by the Centers for Disease Control and Prevention. Of all the pregnancy-related deaths reviewed, 60 percent were considered preventable.

To protect women who are about to give birth, hospitals must have a strong regulatory compliance and patient safety program in place for early identification of risk and to quickly and effectively manage emergencies when they happen. The steps you take to prevent maternal mortality can also help your facility comply with the necessary accreditation requirements for regulatory surveys.

In my experience, as surveyors move from one survey to the next, they become familiar with the standard of care and generally accepted safety practices for a variety of clinical services. They notice when an organization is not keeping up with routine safety practices endorsed by professional organizations. They will often ask which guidelines the organization follows, or may review policies to see when it was last reviewed and whether the references are reputable and current.

Following are tips for how an organization can ensure regulatory readiness in clinical areas that provide care to women and infants.

The right care at the right time

Care delivery should be based on the current state of the science of evidence-based medicine for the population served by the hospital. Organizations often, rightly, adopt evidence-based care delivery practices. It’s important for staff to maintain a close relationship with their discipline-specific professional organization in order to provide the most current, evidence-based care to their patients.

As an example, a project conducted by the Association of Obstetric, Gynecologic, and Neonatal Nurses (AWHONN), defined how staff can accurately quantify blood loss during the birthing process and quickly identify postpartum hemorrhage. To that end, AWHONN advocates the use of a postpartum hemorrhage emergency cart, enabling staff to respond most effectively to this life-threatening obstetrical emergency. In another example, AWHONN and the American College of Obstetricians and Gynecologists endorse the use of the Maternal Fetal Triage Index (MFTI). This tool is used to identify and stratify the risk of mothers and their developing newborns to ensure that those at the highest risk for harm are seen most quickly when presenting for outpatient or hospital-based care.

Important focus areas

Hospitals should also focus on these areas to ensure they are delivering the highest quality of patient care and are meeting all accreditation requirements.

High-level disinfection (HLD) and sterilization. Processes related to disinfection and re-sterilization of surgical instruments must be conducted meticulously since lapses may risk transmitting infection from one patient to another. Leaders should ensure staff are properly conducting HLD on transvaginal ultrasound transducers, followed by storing the processed transducer in a manner that will prevent recontamination.

Deficiencies in proper pre-treatment of surgical instruments, to include speculums and vaginal or cesarean surgical sets, is another frequently scored survey item. Surveyors will look to see which professional guidelines the organization has adopted and survey to those standards. In the case of instrument reprocessing, the most frequently adopted standard is AAMI/ANSI ST79, a comprehensive guide to steam sterilization and sterility assurance in health care facilities.

Titration orders: labor induction and augmentation. The use of medication titration orders has received increased attention on survey over the past year. Surveyors look to ensure hospital policy defining the use of titration orders includes seven elements: medication name, administration route, initial dose, titration dose increment, titration dose frequency, maximum dose, and desired clinical parameter or effect the medication is being titrated to achieve.

Titration of oxytocin in the labor and delivery unit is subject to this requirement. Most frequently, if this item is non-compliant, it’s due to not having one or more of the seven elements defined in the medication order, with lack of including the desired clinical parameter being the element most often missing. To avoid a finding of non-compliance on survey, the definition should be included within the medication order, often found in the detail section, or within the protocol.

Titration protocol. A second issue related to oxytocin management is the result of improper use of a titration protocol. Remember that there must be an order to use the protocol and that the protocol must be included as a permanent part of the patient’s medical record. The protocol included in the medical record must be the version that was in place at the time the medication was administered.

Ensure that an additional order is obtained whenever a deviation from the protocol is required. It’s common for a nurse to stop, restart or vary the titration dose without an order to support it. As one might expect, running the medication in a manner that’s different from the order will result in a determination of non-compliance on survey.

Surgical considerations. The full range of standards that apply to surgical services performed in the main operating room or a hospital-based ambulatory surgery center also apply to an operating room in a labor and delivery unit. This includes pre-op, PACU and anesthesia care.

Labor epidural anesthesia and analgesia. The nurse practice act of most states limits the administration of anesthetizing agents to nurses with advanced education specific to anesthesia care, primarily certified registered nurse anesthetists. There are a few states that allow RNs to administer anesthetizing agents; however, those that do typically place some restrictions on the practice and require additional hospital or state-endorsed education and competency assessment regarding the practice. Since so few states allow this, when surveyors encounter RNs who participate in epidural management they tend to review the practice very carefully.

The area most likely to result in a determination of non-compliance, with the potential to negatively affect the overall accreditation status of the organization on survey, is when nurses initiate or change the labor epidural rate outside of the scope of nurse practice within their state. Surveyors are highly attuned to this issue due to reported instances of serious harm and death because of inappropriate management of epidural anesthesia. These instances specifically point to the incorrect administration of antibiotics instead of analgesia medications via epidural in the labor and delivery area.

A regulatory survey is a very stressful time for staff. Fostering staff awareness of risk points that are often reviewed during survey can reduce stress and enhance how staff relate to surveyors. Monitoring professional organization position statements and guidelines, along with fostering a continuous regulatory readiness mindset creates a safer environment for hospital staff and, above all, result in safer care and happier, healthier moms and babies.

Have questions or want to get your staff prepared for an upcoming accreditation survey? Click here.

About the author. In his role as accreditation advisor for Vizient, Rob Durkee provides accreditation and regulatory services to member organizations, along with content expertise on CMS Conditions of Participation and The Joint Commission (TJC) accreditation standards interpretation. Additionally, he conducts compliance assessments and on-site or virtual coaching during TJC surveys, as well as delivering educational presentations on accreditation and CMS compliance topics. Durkee has more than 29 years of experience executing patient safety and quality improvement programs, serving in various clinical and leadership roles. His clinical and practice settings were predominantly in the perinatal area, specifically labor and delivery.


All Other Multimedia: 
Preview image

Related Materials