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Do you meet the new CMS requirements?

The Centers for Medicare and Medicaid Services (CMS) released the Evidence-based best practices for hospitals in managing obstetric emergencies and other key contributors to maternal health disparities memorandum on December 7, 2021 (QSO-22-05-Hospitals).

As part of the requirement outlined in the memorandum, hospitals must report on the Maternal Morbidity Structural Measure.

Beginning with October 1, 2021, discharges, CMS adopted a new structural quality measure for the Hospital Inpatient Quality Reporting (IQR) Program that asks hospitals to attest to whether they participate in a statewide and/or national maternal safety quality collaborative, and whether they have implemented patient safety practices or bundles to improve maternal outcomes. Specifically, hospitals participating in the Hospital IQR Program that provide inpatient peripartum care will be required to respond to the following questions for the fourth quarter of 2021 and then, beginning in 2022, on an annual basis:

Does your hospital or health system participate in a Statewide and/or National Perinatal Quality Improvement Collaborative Program aimed at improving maternal outcomes during inpatient labor, delivery, and postpartum care, and has implemented patient safety practices or bundles related to maternal morbidity to address complications, including, but not limited to, hemorrhage, severe hypertension/preeclampsia or sepsis?

The American College of Obstetrics and Gynecology provides the following information regarding this measure:

What are Perinatal Quality Collaboratives (PQCs)?

Perinatal Quality Collaboratives (PQCs) are state or multi-state networks of multidisciplinary teams of perinatal health care providers and public health professionals working together to improve outcomes in maternal and infant health. This work is conducted through the implementation of quality improvement (QI) initiatives designed to continually monitor, analyze, and improve the quality of care provided.

For example, the Alliance for Innovation on Maternal Health (AIM) is a national, data-driven maternal safety and QI initiative coordinated by PQCs in many states. They include bundles, which are evidence-based standardizations for delivering care for leading known causes of preventable severe maternal morbidity and mortality. These bundles include:

  • Obstetric Hemorrhage
  • Severe Hypertension in Pregnancy
  • Safe Reduction of Primary Cesarean Birth
  • Obstetric Care for Women with Opioid Use Disorder
  • Cardiac Conditions in Obstetrical Care
  • Postpartum Discharge Transition (in development)

Why is this measure important?

Maternal morbidity and mortality are long-standing issues that continue to impact pregnant women and individuals across the country. This even further exposes health inequities faced by women of color, as Black women are three times more likely to die from pregnancy-related complications than non-Hispanic White women. Finding ways to tackle this issue is a prime focus of ACOG advocacy and policy initiatives, and a priority of the Department of Health & Human Services. ACOG believes PQCs are an important tool in the arsenal in fighting maternal morbidity and mortality.

Minnesota participates in the National Network of Perinatal Quality Collaboratives through the Centers for Disease Control.

The Minnesota Perinatal Quality Collaborative (MNPQC) is a network of organizations, medical providers, content experts, and community voices led by Minnesota Perinatal Organization (MPO) in partnership with the Minnesota Department of Health (MDH). We seek to improve perinatal and infant health outcomes with an emphasis on improving health equity for all birthing people.

Birthing Hospitals throughout Minnesota can meet the new CMS requirement through participation in the Minnesota Quality Care Collaborative.

For more information and how to get involved, visit our website links below.

Maternal Hypertension Initiative

MOSTaRE Initiative

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