One Texas hospital wasted no time getting its maternal care verification survey process underway this summer. The Texas Perinatal Services team recently returned from El Paso, where surveyors spent two days onsite at the Level IV facility. In addition to Vice President of Operations Brenda Putz and Perinatal Program Manager Carla Rider, the survey team included a maternal fetal medicine physician, an OB-GYN physician and a maternal nurse. Key hospital personnel participating in the process included the Maternal Medical Director and maternal program managers, hospital senior leadership and representatives from all departments supporting maternal medicine.

“To use our time and the hospital’s time most efficiently, TETAF/Texas Perinatal Services prepares the hospital in advance so they are aware of all of the documents and medical records that will be requested,” says Putz. “We send the hospital a pre-survey questionnaire that helps ensure they are fully prepared for the site review.”

The two days onsite begin with interviews of the hospital leadership team, followed by a facility walk-through to review the hospital and talk with bedside staff. Surveyors get a snapshot of the hospital’s program during this time and the findings are discussed at the exit conference. “Our survey includes an in-depth record review, review of policies, review of QAPI and data collection,” adds Rider.

To help facilitate the process, the hospital is asked to assign a medical record navigator to each surveyor. “It is critical that the navigator has access to all the medical records we will review, including archive records, as they could be 12 to 18 months old,” she says.

It is also important that the hospital set aside adequate work space for the survey team, which is onsite from 1:00 – 6:00 pm on the first day and 8:00 am – 2:00 pm. on the second day. “We need sufficient space for the surveyors to work with their navigators to review the medical records efficiently and also to provide education as we go through the process,” notes Putz.

Texas Perinatal Services provides its survey report to the hospital within 30 days of the site survey along with all medical records reviewed. “It is then up to the hospital to submit the report, the medical record review and their application to the state regarding their designation. It is important to remember Texas Perinatal Services doesn’t have the authority to designate a hospital, it is only within the authority of the Texas Department of State Health Services,” she adds.