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CABC Indicators - STANDARD INDICATORS

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					              The Commission for the Accreditation of Birth Centers
                     32 Evans Road  Eagleville, PA 19403
                   610.630.5885  CommissionABC@gmail.com

                              STANDARD INDICATORS
The CABC has developed indicators for some of the standards to assist site visitors with the performance of an
accreditation site visit. Not all standards were deemed to require indicators, and these indicators may be
modified in the future.
These indicators are to be used as guidelines and are not meant to be a do-all, be-all comprehensive list.
The standards addressed include:

Standard 2 – Organization
2.1 A separate organization                                                                           3
2.2 Governing body meets regularly                                                                    3
2.4 Governing body responsibilities                                                                   3
2.5 Mechanism for consumer advice                                                                     4

Standard 3 – Administration
3.3 Accounting principles                                                                             5

Standard 4 – Facility, Equipment & Supplies
4.1 Complies with licensure regulations                                                               6
4.2 Complies with codes, OSHA and ADA regulations                                                     6
4.3 Fire safety                                                                                       6
4.4 Record of routine inspections re: public safety                                                   6
4.5 Fire safety drills                                                                                7
4.6 Prohibits smoking                                                                                 7
4.7 Guards against environmental factors                                                              7
4.8 Ventilation and lighting                                                                          8
4.9 Provides adequate space                                                                           8
4.10 Housekeeping services                                                                            8
4.11 Hand-washing facilities                                                                          9
4.12 Space for clothes – inclement weather                                                            9
4.13 Trash storage and removal                                                                        9
4.14 Disaster plan                                                                                    9
4.15 Maternal emergency cart                                                                          9
4.16 Newborn emergency cart                                                                          10
4.17 Properly maintained equipment                                                                   10
4.18 Properly maintained accessory equipment                                                         11
4.19 Inventory of supplies is sufficient                                                             11
4.20 Shelf life of medications and supplied monitored                                                12
4.21 Proper storage of needles, syringes and scripts                                                 12

Standard 5 – Quality of Services
5.1 Client rights                                                                                    13
5.2 Range of services                                                                                14
5.3 Interventions not recommended or appropriate                                                     14
5.4 Protocols provided to consulting specialists and hospitals                                       15
Standard Indicators                                                           page 2




Standard 6 – Staffing & Personnel
6.1 Staff and consulting specialists provide evidence of knowledge                     16
6.2 Staff and consulting specialists licensed                                          16
6.3 Adequate numbers of professional and support staff                                 16
6.6 Adult and neonatal CPR                                                             16
6.7 Personnel records are maintained and secured                                       17
6.9 Staff development                                                                  18
6.11 OSHA annual training                                                              18
6.12 Patient safety and privacy                                                        19

Standard 7 – The Health Record
7.1 Record form                                                                        20
7.2.A Health record – demographic information                                          20
7.2.B Orientation to program, informed consent, payment plan                           20
7.2.C Complete history                                                                 21
7.2.D Initial exam, labs and risk assessment                                           21
7.2.E Referral of ineligible clients                                                   21
7 .2.F Continuous periodic prenatal exam and risk assessment                           22
7.2.G Instruction and education                                                        22
7.2.H Admission exam and risk assessment                                               22
7.2.I Labor assessment of mother and fetus                                             22
7.2.J Consult, referral, transfer for maternal/neonatal problems                       23
7.2.K Labor and birth summary                                                          23
7.2.L Postpartum/newborn assessment                                                    24
7.2.M Ongoing maternal/newborn assessment                                              24
7.2.N Maternal/newborn discharge summary                                               24
7.2.O Home care, follow-up and referral                                                25
7.2.P Newborn health supervision and required screening tests                          25
7.2.Q Late postpartum evaluation of mother/family planning                             25
7.2.R Screening/referral for mood disorders                                            25
7.3 Reports documented promptly                                                        26
7.4 Mechanism for transferring records                                                 26
7.5 Health records are protected                                                       26
7.6 Systematic review of records/attention to problems                                 26
7.7 Medical record system                                                              27
7.8 Responsibility for processing health records                                       27

Standard 8 – Evaluation of Quality of Care
8.1 Quality improvement program                                                        27
8.2 Collection and analysis of data                                                    28
8.4 Evaluation of client satisfaction                                                  29
8.7 Re-evaluation of actions taken to resolve problems                                 30

Standard 9 – Research Activities
Conduct of research                                                                    31

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                  page 3



                         STANDARD 2 – ORGANIZATION
Successful compliance to the Standard shall include but will not be limited to the following:

2.1 The birth center is governed as an organization that is separate from other health, hospital
    or medical services and has its own governing body or is part of a larger legally constituted
    healthcare organization and has representation to that governing body.

    Indicators for Compliance:
        • Representation on the governing body
        • Separate bylaws?
        • Control of budget or has significant input into development of budget
        • Control of policies and procedures?

2.2 Governing body or the designated birth center directors meets regularly to execute
    responsibilities for operation of the center and maintain minutes of the meeting.

    Indicators for Compliance:
        • Minutes of meetings available.

2.4 Governing body responsibilities, direct or delegated, include but are not limited
    A) Formulation of missions, goals and a long-range plan for the center
    B) Development of organizational structure and bylaws, which clearly delineate lines of
       authority and responsibility
    C) Appointment of qualified administrative director
    D) Appointment of qualified director of the professional staff
    E) Approval of policies and procedures for the operation of the center
    F) Approval of qualifications of applicants for professional staff
    G) Approval of a program of quality improvement for the operation of the center and the
    care provided
    H) Review and action on all legal matters relating to the operation of the center
    I) Financial management and accountability

    Indicators for Compliance:

        New Hires:
        • Are pre-employment background checks performed for new hires in sensitive positions to
           identify previous dishonest or unethical behavior (e.g. criminal records and convictions,
           Social Security number verification, credit history, previous employment and employment
           references, civil records and judgments)?
        • Are employees in sensitive positions required to take annual vacations?

        Access:
           • Are doors, desks, and file cabinets containing sensitive data kept locked with keys
               secured, or is access otherwise restricted?

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                  page 4


             •   Do formal procedures exist for granting and terminating access to center facilities,
                 including computer system, and are such procedures followed?
             •   Is access to computer system restricted via passwords, required employee ID, or other
                 means?

        Receipts:
           • Are periodic tests performed to ensure that services rendered are billed?
           • Are periodic tests performed to ensure that billed amounts have either been collected
               and appear on the receipt copy of a deposit slip or are still in billed receivables, and
               have been followed up on if greater than sixty days old?
           • Are customers or third party payers instructed to make payment directly to the center’s
               bank account?
           • Are checks restrictively endorsed on receipt?
           • Is cash independently controlled on receipt?
           • Does a person who does not receive cash or checks for deposit produce a record of
               daily/weekly cash receipts itemizing the receipts for the period?
           • Are the daily/weekly cash receipts records matched to the receipt copy of deposit slips?
           • Are deposits per bank statements matched to the receipt copy of the deposit slips?

     J) Establishing charges for services
     K) Prohibition of discrimination in operation and provision of services
     L) Approval of all contracts and agreements with individuals or service agencies, such as
        hospitals, laboratories, emergency transport, consulting specialists, teaching institutions
        and organizations conducting research
     M) Access to and retrieval of all revenue and expense information specific to the birth
        center

    Indicators for Compliance:
        • Policy and Procedures, bylaws or minutes of meetings demonstrating a thru m.

2.5 The governing body establishes a mechanism for consumer advice on the services and
    functioning of the birth center.

    Indicators for Compliance:
        • The governing body insures there is an effective mechanism for receipt of advice and
            information from consumers and demonstrates the effect of this input on the policy and
            operation of the center.




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                   page 5



                       STANDARD 3 – ADMINISTRATION
Successful compliance to the Standard attributes shall include but will not be limited to the following:

3.3 There is evidence of adherence to generally accepted accounting principles including but not
    limited to a review of financial statements every six (6) months and approval of the annual
    budget by documentation in minutes from meetings of the governing board or its directors.

    Indicators for Compliance:
        • There is an annual budget.
        • There is documented evidence that the governing body has approved that annual budget.
        • Is the budget balanced, (i.e., projected revenues = projected expenditures) in the black?
            (i.e., projected revenues exceed projected expenditures)?
        • If the budget is in the red, (projected expenditures exceed projected revenues), how will the
            shortfall be covered?
        • There are financial statements (budget vs. actual revenues and expenditures) at least every
            six months.
        • If the center has audited financial statements, the report should include an assessment of
            the adequacy of internal accounting controls.
        • There is a plan in place to cover short-term cash shortfalls.
        • What financial controls exist to protect the center from embezzlement or diversion of
            funds?
                 ► Person(s) authorized to sign checks should not be the same as the person authorized
                 to balance bank statements.
                 ► There is a mandated counter-signature on checks that exceed a certain amount.
                 ► There is a reliable system for recording all receipts, including cash receipts, that
                 involves matching each receipt to the service provided and the specific client who
                 received that service.
                 ► There is a petty cash policy and a system for tracking petty cash expenditures.
                 ► Person(s) ordering and receiving supplies and equipment is not the same as the
                 person who pays the bills.




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                      page 6



     STANDARD 4 – FACILITY, EQUIPMENT AND SUPPLIES
Successful compliance to the Standard attributes shall include but will not be limited to the following:

FACILITY
4.1 Complies with regulations for licensure of birth center, if established for its jurisdiction.

    Indicators for Compliance:
    • License is:
        ► current
        ► displayed, if required
        ► policies and procedures of the center do not violate licensure regulations for the jurisdiction
        the birth center is in.

4.2 Complies with applicable local, state and federal codes, regulations, including current OSHA
    and ADA regulations and ordinances for construction, fire prevention and public safety and
    access.

    Indicators for Compliance :
    • Certificate of last fire inspection.
    • Needle boxes in each birth and exam room – refer to OSHA indicators on Standard 6.11.
    • Evidence of annual in-service on infection control – refer to OSHA indicators on standard 6.11.
    • Accessible to handicapped visitors.
    • Overall safety and security for staff and client (i.e., parking lots lit at night, doors secured at all
        times, provisions for on-call personnel to enter safely.

4.3 In the absence of community fire regulations, the birth center maintains functioning smoke
    alarms, appropriately placed fire extinguishers, emergency powered lighting, identified exits,
    stairwell protected by fire doors.

    Indicators for Compliance:
        • Verify smoke alarms in working order. How determined? Ask birth center to demonstrate.
        • Is there a fire extinguisher in the kitchen? Near birth rooms? Near laundry area?
        • Was the emergency-powered lighting charged during the past year? How tested? Site
           visitor should test, if possible.
        • Are there lighted exit signs?
        • No open stairs.
        • Fire doors closed.

4.4 Maintains a record of routine periodic inspections by health and fire departments, building
    inspectors and other officials concerned with public safety, as required by the center’s local
    jurisdiction.

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                              page 7


    Indicators for Compliance:
        • Verify last inspections of each:
                ► health
                ► fire
                ► building
                ► other

4.5 Provides instruction for all personnel on fire safety and conducts at least semi-annual
    evacuation drills.

    Indicators for Compliance:
        • Confirm instruction is provided.
        • Instruction is where the birth center says it is.
        • Confirm dates of last two drills.
        • Confirm drills held twice yearly since the last accreditation.
        • Ask a staff member to describe the fire evacuation procedures.

4.6 Prohibits smoking in the birth center.

    Indicators for Compliance:
        • Confirm there are no ashtrays.
        • Written “no smoking” policy for clients.
        • Posted “no smoking” sign.

4.7 Guards against environmental factors that may cause injury from falls, electrical shock,
    poisoning and burns; with particular attention to hazards to children such as uncovered
    electrical outlets, unsafe toys, unprotected stairs and unlocked storage cabinets as well as
    walkways, parking lots and outside play areas.

    Indicators for Compliance:
        • Electrical outlets covered.
        • Electrical cords pose no danger—not frayed, no extension cords, no cords under rugs or in
            location with risk of tripping over cord.
        • Kitchen cupboard doors and drawers childproofed.
        • Dishwasher soap, cleaning supplies, knives stored in childproofed manner.
        • Medications are secured from children/clients.
        • Water temperatures in safe range, and bottled water machines that supply hot water have
            childproof spouts.
        • Stairways protected, handrails available and are well-lit.
        • Sidewalks, parking lot in good repair.
        • Rails in bathtubs, safety mats.
        • Grounded outlets near sinks/water.
        • Electric appliances out of reach of children.
        • Toys:
                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                    page 8


             ► have no small parts
             ► are clean
             ► are in good repair
             ►facility safety records   show evidence of regular inspection and cleaning of toys

4.8 Provides adequate ventilation and lighting.

    Indicators for Compliance:
        • Ventilation is appropriate for climate.
        • Emergency lighting can be demonstrated (in case of power failure).
        • Lighting available for episiotomy repair, newborn exam.

4.9 Provides adequate space for caseload and personnel and insures privacy for women and
    childbearing families including but not limited to:

     A)   Business operations
     B)   Secure medical records storage
     C)   Waiting reception area
     D)   Exam rooms
     E)   Family room and play area for children
     F)   Bath and toilet facilities for families, laboring women and staff
     G)   Birth rooms
     H)   Staff area
     I)   Educational facilities/library
     J)   Utility and work area
     K)   Storage
     L)   Area for emergency care
     M)   Accommodation for non-ambulatory family member (non-ambulatory childbearing
          women are not usually cared for in birth centers

    Indicators for Compliance:
        • Confirm diagram of birth center floor plan reflects reality.
        • Confirm privacy is assured for moms.
        • Confirm privacy is assured for families.
        • Check all patient areas for accessibility of prescription pads, needles, syringes.
        • Check accessibility of medical records to non-medical people.
        • Assess if medical records are protected against loss from fire and theft.
        • Staff has separate bathroom facilities from clients.
        • Staff has separate area for meals and reports.

4.10 Provides adequate housekeeping services to maintain a sanitary home-like environment.

    Indicators for Compliance:
        • How does staff assure the rooms and baths have been cleaned between families?
        • Confirm that appropriate cleansers and cleaning methods are used.
                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                       page 9


         •   Records are kept of terminal cleaning.
         •   Floor coverings are appropriate for a birth center; cleaned appropriately.
         •   No loose rugs.
         •   How are linens such as bedspreads/pillows cleaned?
         •   No food in medication refrigerator, thermometer present.
         •   Separate dirty and clean areas available for equipment care.
         •   No trash stored near furnace or hot water heater.

4.11 Provides adequate hand-washing facilities for childbearing families and personnel.

    Indicators for Compliance:
        • Sufficient, convenient sink locations.
        • Paper towels and soap convenient and in adequate supply.
        • Provisions are made for children to be able to safely reach a sink for hand-washing.

4.12 Provides adequate space for coats, boots and umbrellas in inclement weather where
appropriate.

    Indicators for Compliance:
        • Space for appropriate climatic conditions.

4.13 Provides adequate sanitary trash storage and removal including biomedical waste and
human tissue.

    Indicators for Compliance:
        • Reviews contracts or policy for hazardous waste removal.
        • Where is trash stored until pickup?
        • Clearly marked bags available for biohazardous waste.
        • Storage space is adequate for volume of caseload and frequency of pick-ups.

4.14 Has a disaster plan in place, including equipment or plan for snow removal where
appropriate and to secure the facility in the event of major storms, floods, etc.

    Indicators for Compliance:
        • Verify equipment available or:
            ► plan for snow removal.
            ► has disaster plan, any drills conducted?
            ► staff knows location of disaster plan.
            ► a copy of the disaster plan is located off the premises.
            ► have staff member describe how they would deal with a storm.




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                   page 10



EQUIPMENT
4.15 A readily accessible emergency cart or tray for the mother is equipped to carry out the
written emergency procedures of the center and securely placed written log of routine
maintenance for readiness.

    Indicators for Compliance:
        • Cart or tray:
            ► is accessible for all birth rooms and readily available when there is a client in the center
            ► is neatly arranged so everything is available
            ► is locked to prevent loss of supplies
        • Sanitary condition of cart assured
        • Log is available.
        • Log is maintained.
        • At a minimum, center must provide access to the following medications:
            ► EPI 1:1000 (required), Benadryl (recommended)
            ► Pitocin
            ► Methergine or misoprostol
            ► IV fluids

4.16 A readily accessible emergency cart or tray for the newborn is equipped to carry out the
written emergency procedures of the center and securely placed with a written log of routine
maintenance for readiness.

    Indicators for Compliance:
         • Cart or tray:
             ► is accessible for all birth rooms and is readily available when there is a client in the
             center
             ► is neatly arranged so everything is available
             ► is locked to prevent loss of supplies
             ► Emergency equipment, including laryngoscope light bulb, is in working order
         • Sanitary condition of cart assured.
         • Log is available.
         • Log is maintained.
         • At a minimum center must provide access to the following:
             ► EPI 1:10,000
             ► Narcan (if center offers narcotics in labor)
             ► Oxygen
             ► Intubation supplies including ET tubes in the appropriate sizes, laryngoscope with
             appropriate-sized blade(s) and extra batteries and light bulbs
             Note: This equipment must be available in the center even if its use by the primary
             provider in the center is prohibited by state practice regulations.
             ► Heat source - If the heat source is a heating pad, there is a policy for avoiding direct
             contact and radiant burns of infant.

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                            page 11


4.17 Properly maintained equipment for routine care of women and neonates including but not
limited to:

             A) A heat source for infant examination or resuscitation
             B) Transfer incubator or isolette or demonstrated capability of ready access to
                transfer incubator
             C) Sterilizer or demonstration of sterilizing capability
             D) Blood pressure equipment, thermometers, fetoscope/doptone, equipment for
                newborn exam
             E) Intravenous equipment
             F) Oxygen equipment for mother and newborn
             G) Instruments for delivery, episiotomy and repair

    Indicators for Compliance:
            • Confirm all equipment on list is available.
            • How is it determined that each piece of equipment works? Records are kept indicating
                regular checks of equipment.
            • Test laryngoscope to confirm that it is working.
            • Open and close oxygen tanks; check for masks and tubing.
            • Are there adequate numbers of oxygen tanks readily available to replace empty tank,
                and are they stored securely?
            • Log indicates that sterilizer is tested and cleaned regularly..
            • Electrical equipment, such as exam light, sterilizer, etc, are tested annually for
                electrical leakage.
            • Review cleaning procedures for blood pressure equipment, doptones.
            • Blood pressure cuffs are recalibrated at least annually.
            • Confirm number of IVs and expiration dates.
            • Is there an adequate amount of equipment for maximum capacity of birth centers?

4.18 Provides properly maintained accessory equipment which includes but is not limited to:
          A) Portable lighting
          B) Conveniently placed phones
          C) Kitchen equipment usually found in home for light refreshment
          D) Laundry equipment usually found in home or contracted laundry services

    Indicators for Compliance:
           • Confirm equipment is available and working.
           • Where do staff need to go to call for help?
           • Do they have to leave the client to do so?
           • Are emergency numbers posted beside the phones?
           • Kitchen is clean and equipped for light snacks and drinks.
           • If laundry is done on site, review health department regulations.
           • Review laundry procedure to confirm it is adequate for blood borne pathogens.


                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                 page 12



SUPPLIES
4.19 The inventory of supplies is sufficient to care for the number of childbearing women and
    families registered for care.

    Indicators for Compliance:
        • Stock of supplies is adequate for the number of families currently registered for care.

4.20 Shelf life of all medications, IV fluids and sterile supplies is monitored.

     Indicators for Compliance:
         • Log of medications shows expiration dates; checked routinely.
         • No medications, IVs for mother or infant and sterile supplies are out of date.

4.21 Supplies such as needles, syringes, and prescription pads are appropriately stored to avoid
public access.

     Indicators for compliance:
            • Appropriate containers for sharps in exam and birth rooms.
            • Syringes and needles are stored in a location and manner that minimizes the risk of
                diversion.
            • Prescription pads are appropriately secured.
            • No pre-signed, blank prescriptions are in evidence.
            • How are old pads disposed?




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                    page 13



                      STANDARD 5 – QUALITY OF SERVICES
Successful compliance to the Standard attributes shall include but will not be limited to the following:

The birth center provides high quality, family-centered, maternal and newborn services to
healthy women anticipating an uncomplicated pregnancy, labor and birth that reflect applicable
professional standards for conduct of the practitioners responsible for services rendered and
recognize the basic human rights of the childbearing woman and her family.

        Indicators for Compliance:
        At a minimum, center should have a policy and procedure or risk criteria to reflect
        the following are inappropriate for birth in the center.
                ► Breech or non-vertex at labor and delivery
                ► Gestation < 36 weeks or > 42 weeks
                ► Multiple gestation
                ► Insulin dependent diabetic, including GDM A-2
                ► Certain VBACs

                      Indicators for compliance for VBACs with one or more successful prior VBACs:
                      • Only one prior cesarean.
                      • Client has a documented low transverse incision.
                      • Ultrasound demonstrates placental location is not anterior and low-lying (i.e.,
                          not over the old scar).
                      • Client has signed a VBAC-specific informed consent.
                      • Client meets all other risk criteria of the birth center.

                      Indicators for compliance for primary (first time) VBAC:
                      • Center must document ability to transfer care to a facility with 24/7 availability
                          of anesthesia and obstetrical attendance.
                      • Center must be located in close proximity to its’ transfer facility.
                      • Client meets all the indicators listed above for VBACs with one or more
                          successful prior VBAC.

5.1 That the rights and responsibilities of the woman and her family, however she defines her
    family, are clearly delineated in the center’s policies and procedures and communicated to
    the childbearing family on acceptance for care and that the client’s rights include but not be
    limited to:

     B) Be assured of confidentiality

        Indicators for Compliance:
            • HIPAA guidelines are followed.
            • Notice of privacy practices:
                    ► posted in client area

                       The Commission for the Accreditation of Birth Centers
                              32 Evans Road  Eagleville, PA 19403
                            610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                      page 14


                      ► copy available for client
                      ► reasonable effort to obtain client signature that notice was given
                      ► an individual is identified as the person responsible to oversee that  privacy
                      procedures are implemented and followed (notation in job description or meeting
                      minutes are acceptable)
                      ► staff are trained on privacy practices and practices are implemented. There is
                      evidence of initial training and review on a regular basis. (see Standard V)
                      ►business associate agreements are available as needed for associates that are
                      provided with protected information (i.e., transcription services, nutritional
                      counseling services that review client charts, accrediting bodies that review client
                      charts)
                      ► Agreements are not needed for other providers treating the client, to process
                      billing, or for parties that are not provided with protected information (i.e. cleaning
                      services, maintenance personnel)
                      ► Center’s Policies and Procedures include measures to protect private
                      confidentiality and comply with HIPAA regulations, including a procedure for
                      confirming patient identity when handling phone calls.

5.2 That the center provide or demonstrate availability of a range of services to meet physical,
    emotional, socio-economic, informational and medical needs of the individual client while
    under care including but not limited to:

     L) There shall be strong evidence that the birth center is addressing domestic violence as an
     issue with birth center clients.

        Indicators for Compliance:
            • Does center document domestic violence screening on all clients?
            • Are referral sources available to practitioners?
            • Are materials regarding domestic violence available to clients?
            • There is a means of safely documenting and communicating domestic violence for an
                individual client among the Center’s providers and staff.

        M) There shall be evidence of screening, education and referral for postpartum mood
        disorders.

        Indicators for Compliance:
            • Does center document screening for postpartum mood disorders on all clients?
            • Are referral sources available to practitioners?
            • Are materials regarding postpartum mood disorders available to clients?

5.3 That drugs for induction or augmentation of labor, vacuum extractors, forceps, recorded
    electronic fetal monitors and ultrasound imaging are not recommended during normal labor
    and are not appropriate for use in birth centers.



                       The Commission for the Accreditation of Birth Centers
                              32 Evans Road  Eagleville, PA 19403
                            610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                   page 15


        Indicators for Compliance:
        • Oxytocin:
               ► Only postpartum use is appropriate in birth centers. Written protocol should be in
               place regarding use for postpartum indicators. Example: uterine atony not responsive to
               massage or nursing. Excessive bleeding requiring immediate medical treatment.
                                                                rd
               ► Prophylactic use of IM oxytocin for active 3 stage management of mother with risk
               factors for PPH or 3rd stage complications is also appropriate.
               ► Protocol: Generally should be for intramuscular oxytocin, as intravenous line should
               not be routine. Intravenous use in not a violation of this standard if protocol addresses
               use of intravenous line as part of treatment of postpartum hemorrhage.
               ► Protocols for any antepartum or intrapartum use of oxytocin is a violation of this
               standard.

        •    Prostaglandins:
                ► Are appropriate for postpartum use in the management of postpartum hemorrhage.
                Written protocol should be in place regarding use for postpartum indications. Example:
                Uterine atony not responsive to massage or nursing. Excessive bleeding requiring
                immediate medical treatment. Bleeding not responsive to oxytocin.
                ► Protocol: Generally should be for intramuscular, intramyometrial, rectal or vaginal or
                uterine administration, as intravenous line should not be routine.
                ► Intravaginal, oral or rectal prostaglandin use for cervical ripening or induction is a
                violation of this standard.

        •    Vacuum Extractors and Forceps:
                ► Operative deliveries are not appropriate for use in a birth center, no matter who is
                providing the care.
                ► Not having forceps or vacuum extractors in the center assures compliance with this
                standard.
                ► The center’s equipment should be examined to insure absence of these instruments.
                ► The center’s protocols should be reviewed to insure none address use of these
                instruments.

5.4 Practice protocols be provided to the consulting specialists and available to the hospital
    receiving transfers upon request.

        Indicators for Compliance:
        • Practice protocols signed by consulting specialists OR
        • Ask center how they provide their protocols to their consulting specialists and transfer
            hospital.
        • Note: the center is not required to have practice protocols signed by the consulting
            physicians or the hospital unless such a signature is required by state regulations (e.g.
            practice or birth center regulations) in their state




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                  page 16



               STANDARD 6 – STAFFING AND PERSONNEL
Successful compliance to the Standard attributes shall include but will not be limited to the following

6.1 Professional staff and consulting specialists provide evidence of the knowledge and skills
    required to provide the services offered by the center.

6.2 Professional staff and consulting specialists are licensed to practice their profession in the
    jurisdiction of the birth center.

        Indicators for Compliance:
         • If licensure is not available to non-CNM midwives and the center uses non-CNM
            midwives then:
               ► Center must provide copy of regulations pertaining to midwifery practice in their
               state and these regulations must not prohibit practice by non-licensed midwives.
               ► Midwives for whom licensure is not available must show proof of CPM credentials.
               ► All other attributes of Standard 6 would apply also to any midwives for whom
               licensure is not available practicing in the center.

6.3 There are adequate numbers of professional and support staff on duty and on call to meet
    demands for services routinely provided, and in periods of high demand or emergency, to
    assure client safety and satisfaction; and to assure that no mother in active labor shall
    remain unattended.

        Indicators for Compliance:
        For Non-Licensed Birth Assistants:
         • Assistants must have documentation of current CPR and NRP.
         • Assistants must have a job description outlining responsibilities.
         • Assistants must have documentation of orientation including skill checklist.
         • Assistants must have documented attendance at inservice, emergency drills, OSHA
            training.
         • Assistants must follow state licensing laws regarding attendance at births and postpartum
            care.
         • Assistants should function under the direct supervision of a midwife or RN. This includes
            the RN or midwife remaining in-house when there is an intrapartum or postpartum client or
            a neonate there.

6.6 At each birth there shall be two staff currently certified in:
    A. Adult CPR equivalent to American Heart Association Class C basic life support
    B. Neonatal CPR equivalent to American Academy of Pediatrics/American Heart
        Association

        Indicators for Compliance:
         • One provider at the birth has to be NRP certified to intubate and give drugs.

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                               page 17




6.7 Personnel records are maintained and secured for confidentiality on all employed, attending,
    and contracted staff and include but are not limited to:
    A) Qualifications
    B) Current license where indicated
    C) Health examinations where required
    D) Malpractice insurance carrier or explanation of why malpractice insurance is not
    obtainable
    E) Evidence of malpractice claims
    F) Annual performance evaluations and/or peer review
    G) Evidence of current training and certification for CPR and infant resuscitation

        Indicators for Compliance:
         • Personnel shall be defined as individuals who provide direct care or supervise care
             provided by others in the birth center.
             Note: The birth center is not required to maintain personnel files for collaborative
             physician; however, must have, at a minimum, a copy of current license and
             malpractice coverage.
         • Curriculum vitae and/or application for the position currently held; current copies of any
             required licenses.
         • Current copies of any required certifications (e.g., ACNM, RN, NRP, CPR).
         • Current copy of a malpractice insurance policy.
         • Annual performance evaluations.
         • Documentation that employee has received or read a copy of the Center’s personnel
             policies.
         • Documentation of orientation to the center, including evidence of review of and agreement
             to adhere to center’s policies, procedures, practice guidelines and protocols.
         • Documentation of attendance at any staff in-services, CEU offerings and staff development
             activities.
         • Current health status, including evidence of immunization against Rubella, Hepatitis B or
             signed and dated waiver of refusal.
         • Documentation of required OSHA training and annual updates.
         • Documentation of initial and ongoing HIPAA training.
         • TB screening: Center must determine if it is low-moderate or high risk according to CDC
             guidelines.
             *low risk = less than three TB patients for preceding year
                ► Baseline TB screening upon hire using two step TST or a single BAMT
                ► Additional screening is not necessary unless an exposure occurs
                ► Baseline positive or newly positive test should be followed up with one chest X-ray
                result to exclude TB disease, repeat X-rays are not needed unless symptoms or signs of
                TB disease develop.
            *moderate risk
                ► Baseline screening upon hire using two-step TST or single BAMT
                ►Annual screening


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                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                     page 18


                 ►Baseline positive or newly positive test should be followed up with one chest X-ray
                 result to exclude TB disease, repeat X-rays are not needed unless symptoms or signs of
                 TB disease develop

Some of the above documentation may be included in other files in the center (e.g., staff development,
in-services, etc. may appear in a separate location.

Note: If the center is owned by a larger parent organization and the personnel files are maintained
elsewhere, the center must either maintain a duplicate file or provide the site visitors access to the
original files during the site visit.

6.9 The birth center provides for professional and non-professional staff development including
but not limited to:
       A. Orientation of new staff, including emergency drills

        Indicators for Compliance:
            • There is an orientation checklist, or similar document, that defines the content of an
               orientation for each category of staff – i.e. office, midwife, nurse, birth attendant, etc.
            • There is a completed orientation checklist in the personnel file of every employee.
            • Content of orientation is appropriate for the job description of employee.

        G. Routine, periodic maternal and newborn medical emergency drills.

        Indicators for Compliance:
            • Drills are held at least quarterly and include all appropriate staff.
            • Content of drills is appropriate for the types of emergencies that may be encountered in
               birth centers – including, but not limited to emergency transport of mother or infant,
               hemorrhage, shoulder dystocia, neonatal resuscitation.
            • There is documentation of the drills, including evaluation of performance and
               appropriate follow-up on any deficiencies identified.

6.11 Birth center personnel shall have annual training that meets OSHA regulations and any
    other applicable infection control guidelines.

        Indicators for Compliance:
          • Birth center personnel shall have annual training that meets OSHA regulations and any
             other applicable infection control guidelines.
          • The birth center should be able to provide you with documentation of orientation of all
             new staff to their OSHA program.
             ► a check list with OSHA on it in the personnel file.
             ► an in-service registration sheet with new staff names on it
             ► a signed statement in the personnel file that the employee has been oriented to OSHA
          • The birth center should provide documentation of annual OSHA inservice to staff.
          • Ask to see the birth center’s Material Safety Data Sheets.

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                   page 19


          •    Ask to see the birth centers policy and procedures for use of personal protective
               equipment and check that this equipment is in the center in an amount sufficient to cover
               the volume of clients.
                 ► If the center requires use of cover gowns for births, are they present in the center and
                 in sufficient numbers for client volume?
                 ► Are gloves available in each area where blood is drawn or exams are done?
                 ► Does the housekeeping staff have access to heavy duty gloves as needed?
                 ► Does the center require eye protection for some procedures, and if so, are forms of
                 eye protection on site for staff?
                 ► Ask staff the location of protective attire and inquire whether they actually use it.
          •    Ask to see the federally required posted signs. Are they posted where staff has access to
               them.
          •    Ask to see the center’s Sharps Injury Log.
          •    Ask who is responsible for its OSHA program and what training did this person receive
               for this job. Center should have personnel designated as responsible for this job and be
               able to verify how they were prepared for this duty.
          •    When doing your facility rounds note if all cleaning substances in the facility are in
               containers clearly marked and safely stored with contents and any needed hazard or
               poison labels.
          •    Employers are required to use safer medical devices wherever feasible in order to reduce
               the risk of injury from sharps. The revised standard requires employers to document their
               consideration and the implementation of these devices in the annual review of their
               exposure control plan and document the solicitation and input provided by frontline
               employees in their selection.
               (U.S. Department of Labor Office of Public Affairs, April 12, 2001)


6.12 Training as required by state and federal law in the area of patient safety and
     privacy.

        Indicators for Compliance:
          • Every personnel file contains a signed confirmation of attendance at an initial HIPAA
             training and receipt of the center’s Privacy Practices.
          • There is evidence of annual review of privacy practices.




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                  page 20



                      STANDARD 7 – THE HEALTH RECORD
Successful compliance to the Standard attributes shall include but not be limited to the following:

7.1 The birth center adopts a record form appropriate for use by the practitioners in the birth
    center containing information required for transfer to the acute care maternal and newborn
    hospital service.

        Indicators for Compliance:
             • In practices providing a combination of home, hospital and birth center services, the
                 record reflects clearly which birth site is planned and any change in the planned birth
                 location during the course of the pregnancy.

7.2 The health record on each client includes but is not limited to written documentation of:
      A. Demographic information and client identification

        Indicators for Compliance:
             • Client name on each page.
             • Client’s address, phone (home/work), emergency message phone.
             • Marital status.
             • Age/date of birth.
             • Social security number or other identification. Note: the use of SS# is not encouraged
             • Insurance, payment plan, insurance card number.
             • Employer for client and spouse (spouse, fob).
             • Previous client (yes/no).

        B. Orientation to program and informed consent and including a plan for payment of
        services.

        Indicators for Compliance:
            • If an orientation log is maintained, orientation must also be documented on the client’s
               health record.
            • Informed consent.
            • Agreement to participate.
            • Delineation of the limits of the program.
            • History, physical, lab studies.
            • Special consent if HIV is part of lab.
            • Authorization to treat mother and baby by medical staff as defined by the birth center.
            • Emergency clause covering transfer of care (authorization to transfer).
            • Delineation or risks and glossary explaining terms used.
            • Right to withdraw and method to do so.
            • Newsletter/newspaper/photograph release, if appropriate.
            • Medical record authority to release and receive records.
            • Specimen disposal authorization.
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                             32 Evans Road  Eagleville, PA 19403
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Standard Indicators                                                                    page 21


             •   Affirmation of understanding and acceptance.
             •   Signature of client (and fob if appropriate).
             •   Plan for payment: financial forms containing agreement for payment signed by client.
                 Payment plan clearly delineated.

        C. Complete social, family, medical, reproductive, nutritional and behavioral history

        Indicators for Compliance:
            • Social history: age, education, race/ethnicity, religion, occupation, marital status, living
               arrangements, occupation, exercise, drug use, nicotine use, domestic violence. Family
               history: documentation of family health history, including genetic and hereditary
               diseases. Evidence of screening for appropriate genetic disorders based on individual
               client/family risk factors.
            • Medical history: documentation of client’s health history:
               ►Review of systems
                 ►Genetic
                 ►Psychiatric history
                 ►Illnesses
                 ►Transfusions
                 ►Reproductive/lactation/birth   control - including relevant obstetrical history and sexual
                 ►Menstrual
                 ►Allergies
                 ►Medications/treatments
             •   Nutritional history: evidence of diet history and assessment of adequacy by clinician.

        D. Initial physical examination, laboratory tests and evaluation of risk status.

        Indicators for Compliance:
            • Physical exam
            • Documentation of a complete P.E. on all clients at initial prenatal visit.
            • Note: If client has had care with a previous provider during current pregnancy, a copy
               of those records may substitute.
               ►Screen for infectious diseases, chronic disease, specific assessment of pelvis and
               uterus for normalcy and dates.
            • Laboratory Tests.
               ►Prenatal panel: H & H, type and Rh, antibody screen, hepatitis B screen, serology,
               rubella, culture, urine culture, pap screen.
               ►Optional or follow-up (as indicated) labs: gonorrhea/chlamydia, HIV, hepatitis C,
               marker genetic screening, gestational diabetes screens, repeated blood counts, sickle
               cell screens and other appropriate screens.
               ►Evaluation of risk status: formal risk assessment documented at initial visit.

        E. Appropriate referral on ineligible clients with report of findings on initial screening:



                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                    page 22


        Indicators for Compliance:
            • Use of risk assessment tool evident in referral of ineligible clients.

        F. Continuous periodic prenatal examination and evaluation of risk factors

        Indicators for Compliance:
            • Center must demonstrate periodic evaluation of risk factors. The risk status must be
               documented as per the center’s P&P; however, at least at the following intervals: initial
               visit, each trimester, upon admission in labor.
            • Center will show evidence of a screening and management protocol for Group B strep.
            • Mothers delivering at the center will show evidence of Group B strep screening or
               declination.
            • Screening is done according to recommendations in current CDC guidelines and by a
               qualified lab.
            • Information given to prenatal clients will be consistent with current CDC guidelines.
               Chart review will demonstrate IP treatment according to current CDC guidelines.
            • Infants born to Group B strep positive mothers and mothers with unknown status will
               have monitoring after delivery according to a written protocol developed by the center.

        G. Instruction and education including nutritional counseling, changes in pregnancy,
        self-care in pregnancy, orientation to health record and understanding of findings on
        examinations and laboratory tests, preparation for labor sibling preparation, preparation
        for early discharge, newborn assessment and care.

        Indicators for Compliance:
            • Use of nutritional evaluation tool, (e.g., checklist, weight graph, diet recall).
            • Checklist documenting completion of these attributes or documentation of classes
               covering these attributes.
            • There is evidence that client’s have access to their own records and of participation in a
               program of self-care.

        H. History, physical examination and risk assessment on admission to the center.

        Indicators for Compliance:
            • Documentation of normal labor - noting onset, status of membranes, character of labor,
               nutrition/hydration status.
            • Maternal status – noting frequency, duration and strength of contractions, vital signs,
               reflexes, CVAT, heart and lungs, cervical dilation and effacement; emotional status and
               documentation of support people.
            • Fetal status – noting presentation and position, station, fetal heart rate and character.

        I. Monitoring of progress in labor and on-going assessment of maternal and fetal reaction
        to the process of labor in accordance with accepted professional standards.


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                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                               page 23


        Indicators for Compliance:
        Maternal Vital Signs Intrapartum:
            • On admission, a full set of vital signs should be documented including blood pressure,
               pulse, temperature and respiration.
            • At a minimum there should be documentation of repeat vital signs at least Q4hr.
            • Read the center’s policy and procedures to assure charting complies with the manual.
            • There should be evidence of increased frequency of vital signs in the presence of risk
               factors (ROM, borderline BP, etc.).

        Indicators for Compliance:
        Fetal Heart Tones Intrapartum:
            • Fetal heart tones should be documented on admission to the center in labor, continuing
               FHTs should be taken at a minimum to conform to ACOG’s standards for intermittent
               auscultation.
               ► Active labor – q 30 minutes
               ► Pushing – q 5-15 minutes
               ► Read the centers P & P manual on FHT and if the center mandates more frequent
               FHTs, check that charting complies with their P & P manual

        J. Consultation, referral and transfer for maternal or neonatal problems that elevate risk
        status, including outcome of transfers.

        Indicators for Compliance:
            • Documentation of consultation and transfer when client no longer meets birth center
               criteria.
            • Documentation of time, method of transfer, vital signs upon leaving the birth center.
            • Documentation of third stage medications, management and maternal-infant interaction.
            • Documentation of the outcome of the birth and the status of the mother and/or infant.
               ► vaginal or cesarean birth
               ►Apgars
               ►condition of mother, condition of infant

        K. Labor and birth summary.

        Indicators for Compliance:
            • Documentation of vital signs per birth center protocol in a process that shows ongoing
               assessment with a discharge assessment documented.
            • Documentation of length of each stage of labor and total labor.
            • Documentation of fluid, cord and placental status and character.
            • Mechanism of labor and any unusual management, ie, shoulder dystocia or nuchal cord.
            • Status and care of perineum, description of episiotomy or lacerations and repair.
            • Estimated blood loss and management of excessive loss per protocol.
            • Cord blood studies per protocol.
            • Documentation of medications such as Rhogam, consultations or transfers per protocol.

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Standard Indicators                                                                  page 24


        L. Physical assessment of newborn including Apgar scores, gestational age assessment,
        maternal newborn interaction, prophylactic procedures and accommodation to
        extrauterine life and blood glucose when clinically indicated.

        Indicators for Compliance:
            • Documentation of newborn assessment – Apgar scores, gestational age, blood sugar
               monitoring per protocol, clinical exam, vital signs including color, anthropometric
               measurements (weight, head, chest circumference and length), ongoing assessments per
               birth center protocol with discharge assessment documented.
            • Documentation of nursing/sucking.
            • Documentation of infant behavior and maternal attachment/bonding.

        M. Ongoing physical assessment of the mother and newborn during recovery.

        Indicators for Compliance:
        Maternal Vital Signs Postpartum:
            • There should be a set of vital signs within the first hour postpartum including blood
               pressure, pulse, and temperature.
            • Center should have a policy of continuing vital sign frequency during postpartum stay.
            • Check that charting complies with the center’s P & P manual.
            • There should be a set of vital signs prior to discharge from the center.
            • At a minimum you should find 3 sets of vital signs (admission postpartum, one
               continuing set, one prior to discharge set).

        Indicators for Compliance:
        Newborn Vital Signs:
            • There should be a complete set of vital signs in the first hour after birth including heart
               rate, temperature, respirations, and tone color.
            • The center should have a policy for continuing assessment of newborn vital signs.
            • There should be a complete set of signs prior to discharge.
            • Read the center’s P & P manual for newborn vital signs and check that charting
               documents compliance.
            • At a minimum you should find three sets (first hour post delivery, a continuing care set,
               a discharge set) of vital signs.
            • Check for appropriately increased documentation in the presence of risk factors.

        N. Discharge summary for mother and newborn.

        Indicators for Compliance:
            • Predictive home care discussion with parents.
            • Infant car seat for transport home is documented.
            • Mother and baby show readiness for early discharge as documented by behavior,
               physical assessment and vital signs.


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Standard Indicators                                                                   page 25


             •   Discharge vital signs are documented, as well as, at least two sets of stable vital signs
                 on mother and infant.
             •   Plan for follow-up care is documented.
             •   Infant feeding and status of nursing is documented.
             •   Documents are signed by appropriate personnel with date and time being clearly noted.
             •   Written discharge instructions are provided.

        O. Plan for home care, follow-up, referral to support groups.

        Indicators for Compliance:
            • Plans are documented for home visit, follow-up office visits, pediatrician visit or other
               follow-up per protocol.
            • Disposition to home and plan for care at home is documented.
            • There is documentation that follow-up took place.

        P. Plan for newborn health supervision and required screening tests

        Indicators for Compliance:
            • Pediatrician or other health provider care plan is documented.
            • Plan for neonatal screening tests is documented and there is documentation that the
               testing took place or written documentation of parent refusal.
            • Postpartum care plan is outlined and documented.
            • The center will show evidence of a neonatal hearing screening protocol and
               documentation that information is provided to parents.

        Q. Late postpartum evaluation of mother, counseling for family planning and other
        services.

        Indicators for Compliance:
            • Postpartum visits are documented per protocol and show normal maternal adjustment
               and involution.
            • Infant feeding education and support.
            • Family planning/birth control method is documented.

        R. Screening and referral for postpartum mood disorders.

        Indicators for Compliance:
            • Use of written screening tool such as Edinburgh Postnatal Depression Scale or evidence
               of verbal screening.
            • Center has referral sources for women with postpartum mood disorders.
            • There is evidence that all clients are educated about postpartum mood disorders and
               given information about sources of support and intervention.
            • Prenatal records show evidence of screening for risk factors for postpartum mood
               disorder.

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Standard Indicators                                                                 page 26


             •   There is evidence of screening for evidence of postpartum mood disorders during
                 postpartum phone calls, and home and office visits.

7.3 Reports of laboratory tests, treatments and consultations are entered promptly on health
    records.

        Indicators for Compliance:
            • Reports of laboratory tests, treatments and consultations are entered promptly on health
               records.
            • Documentation of review by appropriate personnel.
            • There is a system in place for tracking lab test and diagnostic procedures ordered to
               assure that results/reports are received in a timely fashion.
            • All consultations with collaborative physicians or other specialists are documented in
               the health record.

7.4 There is a mechanism for providing the birth center with a copy of the prenatal records for
    labor and for sending a copy of the health records with the mother and/or newborn on
    referral or transfer to other levels of care.

        Indicators for Compliance:
            • Policy or protocol for disposition of the prenatal record in instances in which prenatal
               care is provided in a site other than the birth center.
            • Policy or protocol for providing the mother with a copy of her chart or for faxing or
               mailing her record to a higher level of care.

7.5 Health records are protected to insure safe confidentiality and prevent loss but are available
    to practitioners on a 24-hour basis.

        Indicators for Compliance:
            • Charts are secure and inaccessible to the public.
            • There is a policy allowing for access of the client to her own health record.

7.6 There is a system for periodic review of individual client records and attention to problems
    identified.

        Indicators for Compliance:
            • There is evidence of regular review of records of current clients with follow-up and
               discussion of any deficiencies or issues identified.

7.7 A medical record system is established with periodic review, by a qualified individual, of the
    center’s systems, policies and procedures for the maintenance, storage, retrieval and
    retirement of health records consistent with regulatory requirements.




                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
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Standard Indicators                                                               page 27


        Indicators for Compliance:
            • Documentation in minutes of staff or board meetings of the status of the center’s system
               for handling records.
            • Policy or protocol for the handling of records, including records request and release
               procedures that comply with HIPAA regulations.

7.8 Responsibility and accountability for the processing of health records is assigned to an
    individual employed by the center.

        Indicators for Compliance:
            • Policy, protocol or job description for employee responsible for processing health
               records.




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                             32 Evans Road  Eagleville, PA 19403
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Standard Indicators                                                                  page 28



       STANDARD 8 – EVALUATION OF QUALITY OF CARE
Successful compliance to the Standard attributes shall include but will not be limited to the following:

8.1 The quality improvement program for direct maternal newborn care includes but is not
    limited to:

     A. At least annual review of protocols, policies and procedures relating to the maternal and
        newborn care.
     B. The appropriateness of the risk criteria for determining eligibility for admission to and
        continuation in the birth center program of care.
     C. The appropriateness of diagnostic and screening procedures, such as laboratory studies,
        sonography, non-stress tests as they impact on quality of care and cost to the client.
     D. The appropriateness of medications prescribed, dispensed or administered in the birth
        center.
     E. The evaluation of performance of clinical practitioners practicing in the center (peer
        review-self evaluation).
     F. Regular meetings of clinical practitioners to review the management of care of
        individual clients and make recommendations for improving the plan for care.
     G. Regular review of all transfers of mothers and neonates to hospital care to determine the
        appropriateness and quality of the transfer.
     H. Regular review and evaluation of all problems or complications of pregnancy, labor and
        postpartum and the appropriateness of the clinical judgment of the practitioner in
        obtaining consultation and attending to the problem.
     I. Evaluation of staff on ability to manage emergency situations by periodic drills for fire,
        maternal/newborn emergencies, power failures, and natural disasters, that are held
        regularly.

        Indicators for Compliance:
            • Minutes of annual review of protocols, policies and procedures available.
            • Consistent utilization of screening procedures.
            • Documentation of clinical review of management of care to include transfers and
                outcomes.
            • Documentation of peer review and quality assurance activities is appropriate for the
                level of discoverability of such documents in the state.
            • Documentation that staff can manage all facility and maternity-related emergencies.
            • Documentation of a minimum of two yearly (or more if required by state/local fire
                authorities) periodic fire drills.
            • Documentation that staff can manage maternal/newborn emergencies through periodic
                (at least quarterly) emergency drills.
            • Documentation that staff can manage environmental emergencies which may be
                specific to that center, i.e., hurricane, tornado, power outages.



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Standard Indicators                                                               page 29


8.2 The quality improvement program monitors and promotes quality of care to clients and the
    community through an effective system for collection and analysis of data which includes but
    is not limited to:

        A. Utilization of the following services:
               1) orientation sessions
               2) childbirth related educational programs
               3) time in birth center before birth
               4) time in center after birth
               5) home visits postpartum
               6) follow-up office visits postpartum (mothers)
               7) follow-up office visits for newborn
               8) type of anesthesia/analgesia used
               9) neonatal morbidity
               10) maternal morbidity

        B. Outcomes of care provided:
              1) women registered for care
              2) antepartum attrition rate
              3) antepartum transfer rate
              4) preadmission IP transfer rate
              5) women admitted to center for intrapartum care
              6) births in the center
              7) births enroute to the center
              8) maternal intrapartum transfer rate
              9) maternal postpartum transfer rate
              10) newborn transfer rate
              11) type of delivery: NSVD or other
              12) episiotomies
              13) third and fourth degree lacerations
              14) c-section and operative vaginal delivery rates
              15) infants with birth weight: less than 2500 grams or greater than 4500 grams
              16) Apgar scores 6 and below at five minutes
              17) Neonatal mortality and morbidity
              18) Maternal mortality and morbidity

        C. Reasons for transfers:
              1) antepartum
              2) intrapartum, including pre-admit transfers
              3) postpartum
              4) newborn

        Indicators for Compliance:
                    • Evidence of chart reviews of all unanticipated outcomes.
                    • Evidence of compilation of data and utilization to make changes.

                      The Commission for the Accreditation of Birth Centers
                             32 Evans Road  Eagleville, PA 19403
                           610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                    page 30


                      •    Documentation of peer review and quality assurance activities is appropriate for
                           the level of discoverability in the state.
                      •    Each center must have a delivery log with the following items.
                           ► Birth location (unless log is birth center births only)
                           ► Client name or ID number
                           ► Gravidity and parity
                           ► Prenatal issues/problems/complications
                           ► Date and time of birth
                           ► Apgars
                           ►Infant’s weight
                           ►Length of stages of labor
                           ►Date and time of ROM and color of fluid
                           ►Estimated blood loss
                           ►IP/PP/NB complications (if not in a separate transfer log)
                           ►IP/PP/NB transfers (if not in separate transfer log)

8.4 The quality improvement program evaluates client satisfaction with services provided and
    demonstrates a plan to address issues/concerns raised by clients.

        Indicators for Compliance:
         • Examples present of client satisfaction tools, collection and analysis of these data, and one
            change instituted as a result of client evaluations.


8.7 The quality improvement program includes re-evaluation to determine that action taken has
    resolved the identified problem.

        Indicators for Compliance:
         • Center provides evidence that the governing body re-evaluates the results of previous
            actions taken to resolve an identified problem and takes additional action if indicated.




                          The Commission for the Accreditation of Birth Centers
                                 32 Evans Road  Eagleville, PA 19403
                               610.630.5885  CommissionABC@gmail.com
Standard Indicators                                                                   page 31



                      STANDARD 9 – RESEARCH ACTIVITIES
Successful compliance to the Standard attributes shall include but will not be limited to the following:

When research is being conducted by the birth center or by the employees or affiliates of the
birth center or when the birth center is used as a research site, such that the birth center clients
and/or staff are the subjects of research, the research must be conducted by qualified
researchers (defined here has having formal training and/or experience in the conduct of clinical,
epidemiologic or sociologic research) in accordance with written approved research policies and
procedures by staff trained to conduct such research and in a manner that protects the client’s
health, safety and right to privacy and protects the birth center and its clients from unsafe
practices.
1. Protocols for conducting research are approved by the governing body of the birth center
after the review by the professional staff and by the appropriate birth center medical
consultants.
2. Any research activities carried out within the organization are appropriate to the expertise of
staff and the resources of the organization.
3. Rights and welfare of every research subject are adequately protected.
4. Research activity is monitored and progress periodically reported to the governing board.
5. Final results of research activity are reported to AABC, for consideration and dissemination to
other birth centers, and for consideration by the AABC Standards Committee for possible
incorporation in accepted birth center standards of practice.

        Indicators for Compliance:
         • Note if research is being done.
         • If research is being done:
            Is the birth center following its protocols, policies and procedures with regards to these
            research activities?
            A copy of the study protocols is readily accessible to all birth center staff who are involved
            in the research study.
            The birth center has documentation that the study has IRB approval.
            The consent form is on file in the birth center records.
            Birth center’s research policies and procedures reflect that client may decline to participate
            in any research study without being refused access to care in the birth center.
            The birth center’s CQI program includes specific elements designed to review the uses and
            outcomes for any specific procedures normally prohibited under the AABC Standards but
            allowed as a part of a research study.




      Revised: 7/04, 1/05, 8/06, 9/08

                       The Commission for the Accreditation of Birth Centers
                              32 Evans Road  Eagleville, PA 19403
                            610.630.5885  CommissionABC@gmail.com

				
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