Code of Maryland Regulations
Title 30 - MARYLAND INSTITUTE FOR EMERGENCY MEDICAL SERVICES SYSTEMS (MIEMSS)
Subtitle 08 - DESIGNATION OF TRAUMA AND SPECIALTY REFERRAL CENTERS
Chapter 30.08.12 - Perinatal and Neonatal Referral Center Standards
Section 30.08.12.14 - Quality Improvement

III

IV

A hospital shall:

A. Have a multi-disciplinary Perinatal Quality Improvement Program which meets at least quarterly to evaluate maternal and neonatal health outcomes and to identify process changes to improve patient safety and perinatal outcomes.

E

E

B. The Perinatal Quality Improvement Program shall conduct internal case reviews, collect and analyze perinatal program data, conduct trend analyses, set quality improvement goals annually, and use data to assess progress toward those goals.

E

E

C. The Perinatal Quality Improvement Program shall conduct reviews of all cases of the following as well as cases related to other patient safety and systems issues identified:

(1) Maternal, intrapartum fetal, and neonatal deaths;

(2) Transports to a higher or comparable level of care; and

(3) Elective delivery at less than 39 weeks gestation.

E

E

D. Participate with the Maryland Department of Health and local health department Fetal and Infant Mortality Review program.

E

E

E. Participate in the collaborative collection and assessment of data with the Maryland Department of Health and/or the Maryland Institute for Emergency Medical Services Systems, for the purpose of improving perinatal health outcomes.

E

E

F. Maintain membership in the Vermont Oxford Network.

E

E