Why Isn't Nurse Staffing Evaluated as Part of Hospital Accreditation and Quality Designations? : MCN: The American Journal of Maternal/Child Nursing

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ONGOING COLUMNS: Perinatal Patient Safety

Why Isn't Nurse Staffing Evaluated as Part of Hospital Accreditation and Quality Designations?

Simpson, Kathleen Rice PhD, RNC, CNS-BC, FAAN

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MCN, The American Journal of Maternal/Child Nursing 48(1):p 55, January/February 2023. | DOI: 10.1097/NMC.0000000000000871
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In Brief

In 2022, the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) announced new programs to highlight quality in hospital maternity services (CMS, 2022a; CMS, 2022b; TJC, 2022). This focus is critical because maternal morbidity and mortality during the childbirth hospitalization in the United States continue to increase (Agency for Healthcare Research and Quality, 2022; Molina et al., 2022).

CMS is introducing the Birthing-Friendly hospital designation as part of their efforts to improve maternity care and to support the White House Blueprint for Addressing the Maternal Health Crisis (CMS, 2022b; The White House, 2022b). Criteria for the designation are affirmative answers to the two aspects of their maternal morbidity structure measure that requires hospitals with maternity services to report on whether they are participating in a state or national perinatal quality improvement collaborative and whether they have implemented patient safety practices or bundles related to maternal morbidity such as hemorrhage, severe hypertension, preeclampsia, or sepsis (CMS, 2022b).

The Joint Commission, which accredits ~90% of hospitals in the United States, is updating their perinatal certification program beginning in January 2023 that will be known as Advanced Certification in Perinatal Care (TJC, 2022). The Joint Commission notes they are working in collaboration with the American College of Obstetricians and Gynecologists (ACOG) on this process. A list of requirements for the new certification includes 24 pages of details of their elements of performance. Participation in their perinatal core measures data collection is required. There is no mention of nurse staffing as a measure of quality or safety.

Hospitals cannot provide safe, high-quality nursing care without adequate nurse staffing, based on patient acuity and census. Nurse staffing is directly linked to inpatient morbidity and mortality (Association of Women's Health, Obstetric, and Neonatal Nurses [AWHONN], 2022), yet nurse staffing is not included in hospital accreditation processes or these two new initiatives to promote better maternal outcomes. Why not? In England, the Care Quality Commission, the independent regulator of health care, routinely evaluates staffing in hospitals, including maternity services. The Joint Commission is promoting their collaboration with ACOG on their updated perinatal certification, but no professional nurses' organization such as AWHONN is mentioned as a partner. This is a serious omission. Nurses provide the vast majority of hands-on maternity care in the United States and nurses are in leadership positions in every inpatient maternity service.

The White House issued a statement in February 2022 that CMS was going to be assessing staffing in the nation's nursing homes. There is precedent for CMS to evaluate staffing to promote patient safety. Agencies that accredit hospitals in the United States should be assessing nurse staffing based on national standards such as AWHONN (2022) to keep patients safe and support optimal outcomes. Nurses should take an active role in policy discussions and be invited to share national leadership roles in determining what constitutes quality maternity care in the United States.

References

Agency for Healthcare Research and Quality. (2022, May 25). HCUP fast stats: Map of severe maternal morbidity (SMM) among in-hospital delivery. https://www.hcup-us.ahrq.gov/faststats/SMMMap?setting=IP
Association of Women's Health, Obstetric and Neonatal Nurses. (2022). Standards for professional registered nurse staffing for perinatal units. Nursing for Women's Health, 26(4), e1–e94. https://doi.org/10.1016/j.nwh.2022.02.001
Centers for Medicare and Medicaid Services. (2022a, June). Cross-cutting initiative: CMS Maternity Care Action Plan. https://www.cms.gov/files/document/cms-maternity-care-action-plan.pdf
Centers for Medicare and Medicaid Services. (2022b, August 1). FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospitals (LTCH PPS) Final Rule — CMS-1771-F Maternal Health (Fact Sheet). https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospitals-ltch-pps-1
Molina R. L., Tsai T. C., Dai D., Soto M., Rosenthal N., Orav E. J., Figueroa J. F. (2022). Comparison of pregnancy and birth outcomes before vs during the COVID-19 pandemic. JAMA Network Open, 5(8), e2226531. https://doi.org/10.1001/jamanetworkopen.2022.26531
The Joint Commission. (2022, June 20). Advanced Certification in Perinatal Care: Prepublication requirements: New requirements for the Advanced Certification in Perinatal Care. 1–24. https://www.jointcommission.org/-/media/tjc/documents/standards/prepublications/effective-2023/acpc_prepub_jan2023.pdf
The White House. (2022a, February 28). Protecting seniors and people with disabilities by improving safety and quality of care in the nation's nursing homes (Fact Sheet). https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/
The White House. (2022b, June 22). White House blueprint for addressing the maternal health crisis. 1–68. https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf
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