What hospitals need to know
In November 2024, the Centers for Medicare & Medicaid Services (CMS) announced the release of a significant final rule aimed at improving the safety of pregnancy, childbirth and postpartum care. The new conditions of participation apply to obstetric services provided at acute care and critical access hospitals, addressing the country’s ongoing maternity care crisis and marking an important step toward enhancing the quality of care in these settings.
Addressing the maternal health crisis
When CMS says that the country has a “maternity care crisis,” it is no overstatement, says Frank Kolucki Jr., M.D., FACOG, Chairman of Obstetrics and Gynecology at Moses Taylor Hospital in Scranton, Pennsylvania, and a HealthTrust Physician Advisor.
The Commonwealth Fund, a nonprofit private foundation supporting independent research on health policy reform, completed an analysis in 2022 that showed the number of maternal deaths for every 100,000 live births in the U.S. was 22—a figure that is “more than double, sometimes triple, the rate for most other high-income countries in this analysis.”
And while the number of maternal deaths per 100,000 live births in the U.S. came down slightly in 2023 to 18.6, that’s still too high, Dr. Kolucki adds. It’s important to note it doesn’t reflect the full picture—not only is maternal mortality high in the U.S., so is maternal morbidity. “Things like shock, acute kidney injury, myocardial infarction, sepsis—all of these have increased exponentially over the past 10 to 15 years,” he explains. “Maternal mortality is an American tragedy because more than 80% of deaths are preventable.”
CMS Conditions of Participation
A phased approach
With such dire outcomes facing pregnant women in the U.S., CMS felt it needed to act, explains Holly Moore, MSN, RN-K, Senior Director of Clinical Data Solutions with HealthTrust Clinical Services.
“Its goal is to nationally improve our maternal health mortality rate specifically, but improve maternal health overall,” Moore says. “And, so, their thought process is to develop foundational standards of adherence that every hospital must meet in order to participate in the Medicare and Medicaid programs.”
CMS has placed its new conditions of participation into eight categories, with implementation in three phases. The requirements of the first phase apply to all hospitals, whether they have obstetrical services or not, to ensure that emergency departments are properly prepared to handle obstetric emergencies when these patients arrive in the ED. These facilities will be required to have transfer protocols and agreements in place so those patients can be transferred to a facility with obstetric services, if needed.
- Phase 1 (June 2025): Emergency readiness and transfer protocols (applies to all hospitals, including those without obstetric services)
- Phase 2 (January 2026): Organization, staffing and delivery of obstetric services (applies only to hospitals with obstetric units)
- Phase 3 (January 2027): Staff training, quality assessment and performance improvement requirements
“Although compliance may seem daunting, the requirements focus on essential patient safety practices already followed by many high-performing hospitals,” explains Moore.
How Moses Taylor Hospital leads in maternity care
Hospitals can look to other facilities that already do these foundational measures for inspiration and guidance, such as Moses Taylor Hospital. In 2015, it became the first hospital in the U.S. to be certified by the Joint Commission as a perinatal care center, and it has received recognition and numerous awards for its obstetrical services.
Moses Taylor approaches CMS’ eight categories by enacting the following strategies:
- Organization and delivery of service. Taking care of the mother is a team effort that begins in the office, says Teri Evans, RN, BSN, Manager of Moses Taylor’s Labor and Delivery Department, and Diane Grodack, RN, BSN, Moses Taylor’s Director of Women’s and Infant Services. “We realized that any type of change we wanted to make on an outcome needed to actually start in the office setting,” shares Grodack. So, for example, they have social workers who meet with patients in the prenatal office to work with them on breastfeeding and safe sleep practices. They also support opioid-dependent patients to help reduce anxiety about the birthing process.
-
Diane Grodack, RN, BSN Staffing, training and emergency readiness. Staff are cross-trained, and when they onboard new team members, they pair them with one or two preceptors during orientation and keep them on day shift for six weeks before rotating them into night shift. They also do drills and simulation trainings on a regular basis, so staff is up to date on competencies and are prepared for high-risk, low-volume events, such as postpartum hemorrhage or eclamptic seizures. Fortunately, these events don’t often occur, but when they do, everyone needs to be “on their game.”
- Transfer protocols. As a level two maternity center, the team knows what situations they can and cannot care for, says Dr. Kolucki. “We have transfer protocols to tertiary care centers to make sure there is no delay in getting a patient to where they will best be served,” he adds. And if, for example, foul weather delays a transfer, then they rely on the relationships with those care centers to provide advice and recommendations to care for the patient until it’s safe to transfer.
“Over 80% of pregnancy-related deaths are preventable. ”
- Quality assessment and performance improvement. The team members use dashboards to make sure they have appropriate outcomes, and they review their statistics monthly. For example, they evaluate what their rates are for primary section, episiotomy and hemorrhage, and compare their outcomes to the Adverse Outcome Index, a nationally recognized metric that assesses the quality of obstetrical care. “We assess all those things to make sure that there are no outliers,” Dr. Kolucki explains.
They’ve discovered one of the most useful practices from a performance improvement perspective is immediately debriefing after an event, Grodack and Evans add. Even out of a “small” crisis, they’ve learned valuable things that they can implement; those changes are made immediately and are reviewed after implementation to make sure they worked the way they were expected to.
The entire team from multiple disciplines and departments also meets twice every day to review possible high-risk patients and puts plans in place for how to handle those risks should they develop. “It’s the first line of defense in the protection of our patients,” Dr. Kolucki says. “We use the collective intellect of all team members to determine what is the absolute best plan of care for each patient.”
“Most of the things CMS is requiring can be completed in an easy fashion with very simple tools like checklists, drills and simulations,” Dr. Kolucki adds. They aren’t costly to do, and free guides and tools are available from the Alliance for Innovation on Maternal Health, the California Maternal Quality Care Collaborative, the Society for Maternal Fetal Medicine and the American College of Obstetricians and Gynecologists.
Hospitals can also look within their own systems for guidance, says Moore. Smaller hospitals within a larger network can see what processes and procedures are already in place rather than reinventing the wheel.
And HealthTrust has resources for members, too. “We can help service line leaders set up processes so that they’re meeting the CMS conditions of participation,” she adds.
ARE YOU PREPARED to meet the new CMS measures? HealthTrust can help. Contact CDSinfo@healthtrustpg.com or Kim Wright at kimberly.wright@healthtrustpg.com to start the conversation.
Share Email CMS, Compliance, Patient Outcomes, Q2 2025
