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.    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.    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     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: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________