Facility Policy Cover Sheet Evidence-based Perinatal Program

Minnesota Health Care Programs (MHCP)
September 6, 2011
Evidence-based Perinatal Program
Facility Policy Cover Sheet
Effective January 1, 2012, Minnesota legislation asks hospitals to implement policies and
processes designed to minimize non-medically necessary inductions prior to 39 completed weeks
gestation.
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MDHS will verify facility policies meet
the defined evidence-based criteria
through a review process. Hospitals can
submit policies with cover letter to
MDHS at any time to begin the
verification process. A list of verified
hospitals will be posted on the public
website.
If attending OB physician delivers at a
hospital that does not meet these criteria,
they will be required to submit an
additional attachment with delivery
claims.
If these criteria are included in hospital
policies, attending OB providers who
deliver in that hospital will NOT be
required to submit an additional
attachment with delivery claims.
Please fill out and attach all 3 pages of
this cover sheet to the front of your
policy submission. Mark the areas in
the attached policy which reflect
checklist items with highlighter or postits. Please attach any supporting
documents or explanation.
Submit policies to:
Minnesota Department of Human Services
Attention: Fritz Ohnsorg
PO Box 64984
St. Paul, MN 55164-0984
Or email to: [email protected]
Or send Attention to Fritz Ohnsorg via fax
to: 651-431-7420
Facility Name: _____________________________________________________________
Street Address (including City, State, and Zip Code): _____________________________
________________________________________________________________________________
Contact Person Name and Title: ______________________________________________
Phone: __________________________
Policy Checklist
Email: _____________________________
Minnesota Health Care Programs (MHCP)
September 6, 2011
If the following items are included in hospital policies and quality improvement policies,
providers will NOT have an additional data requirement with delivery claims.
Check all that apply:
 The facility has “hard stop” policy restricting elective inductions before 39 weeks, which
includes the following elements:
 Medical indications for induction are defined in policy.
 Quality improvement process to review all deliveries not meeting such policy.
 Hospital staff are authorized to not schedule an elective induction before 39 weeks
completed gestation.
 Providers are required to get permission from physician leadership (e.g., the head
of the OB department) before performing an elective induction before 39 weeks.
 The policy encourages providers to document final estimated date of delivery (EDD) and
includes the following elements:
 EDD is to be documented by 20 weeks gestation
 Documentation is to include data from ultrasound measurement as applicable
 Final EDD is to be shared with the patient
 The policy encourages patient education regarding elective inductions, and requires
documentation of the education patients receive.
 The policy requires ongoing QI review of the following:
 Facility-level reporting of:
Number of elective,* singleton births (induction and/or Cesarean) between 37 -39 completed
weeks gestation/
Total number of singleton deliveries between 37 – 39 completed weeks gestation
*Elective is defined as not having a medical/obstetric indication, as defined in a prescribed list.
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Ongoing audits if the proportion of births using induction at gestations less than
39 weeks is above 25%.
Analysis of provider variation regarding use of elective inductions.
Peer review of all inductions less than 39 weeks for appropriateness of indication.
Comments:
______________________________________________________________________________
______________________________________________________________________________
Steps in Review Process:
Minnesota Health Care Programs (MHCP)
September 6, 2011
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Acceptance letters will be mailed within 5 weeks of receipt of policy.
All rejections will be reviewed by Medicaid Medical Director.
Facilities can resubmit after outstanding items are addressed.
Facilities will be required to re-attest to their policies and QI processes every 3 years.
This section is to be completed by Reviewers at Minnesota
Department of Human Services
Reviewer(s):
________________________
_______________________
Date of review: ________________________
Check one:
 Meets Requirements
 Does Not Meet Requirements
If applicable, justification for rejection:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reviewer comments:
______________________________________________________________________________
______________________________________________________________________________
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