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The Joint Commission Perinatal Standards

Patient simulation can be your key to compliance.

As you may know, on January 1, 2021, The Joint Commission (TJC) began requiring hospitals to implement two new perinatal patient safety standards with a completion deadline of December 31, 2021. The standards have left many organizations grappling with what exactly meets compliance under the new guidance and exploring how best to carry out their efforts.   
 
There are important lifesaving fundamentals in TJC’s standards – standards that patient simulation can help facilitate, especially with regards to its emphasis on “drills.” Patient simulation can help you ensure compliance. At the same time, it can also foster continuous improvement. Studies show that simulation-based drills can correlate to improved patient outcomes1 and even help lead to lower malpractice claim rates
 
In this article, we summarize TJC’s standards and the background on why they were updated. We also provide you with some insight into how simulation-based training can help you meet the TJC’s requirements for drills and position you for long-term continuous improvement. This article is intended primarily for those already working in simulation who are looking for more information on using simulation to comply with TJC standards. This article may also be helpful for anyone in Labor and Delivery who may need a quick resource on the topic.  

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Maternal Mortality Continues to Rise

The United States boasts some of the best medical schools, hospitals, and clinicians in the world, yet maternal mortality in the United States has continued to climb over the last few decades. According to the U.S. Centers for Disease Control and Prevention, 861 women were identified in 2020 as having died of maternal causes in the United States, compared with 754 in 2019.2 The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births compared with a rate of 20.1 in 2019.3 The rate is now more than double what it was 30 years ago.4 The United States ranks sixty-fifth among industrialized nations in maternal deaths,5 and data shows massive disparities for women of color.6

The leading causes of maternal morbidity and mortality are hemorrhage and hypertensive disorders of pregnancy.7,8 Hemorrhage itself is the leading cause of maternal mortality worldwide.9 While hemorrhage can occur at any time during labor and delivery, it most commonly occurs postpartum and is defined by the term postpartum hemorrhage (PPH).

PPH is both common and incredibly dangerous, given how quickly a mother can bleed out. This is important in the context of structuring simulation drills. Labor and delivery teams need to recognize what’s happening, determine the cause, give medications, transfuse, resuscitate, and, if needed, transfer the patient to the operating room. PPH represents a radical change in the patient’s condition—and this a prime opportunity for simulation-based training.

Hypertensive disorders can also turn a patient case into an emergency. Identification of severe hypertensive disorders followed by rapid control by the labor and delivery team are essential—another area where patient simulation can help. 

TJC Has Taken a Strong Stand on Maternal Outcomes

As an independent not-for-profit organization, TJC serves as the largest accrediting body for healthcare institutions in the United States. Hospitals certified by TJC are surveyed at least once every 3 years, and many hospital departments prepare for on-site visits far in advance.

TJC has been one of the leaders in highlighting a reality that has been the focus of patient safety advocates for years: communications failures are a leading contributing cause of patient harm.10 In a review of malpractice cases examined by CRICO Strategies, a research and analysis branch of the company that insures Harvard-affiliated hospitals and providers, communication failures were a factor in 36 percent of the cases.11

In 2019, TJC issued their requirement entitled, Provision of Care, Treatment, and Services Standards for Maternal Safety.12 TJC did this as part of their “Requirement, Rationale, Reference” or “R3” series, which TJC uses to express any newly-issued standards. In the maternal safety R3, TJC advises that hospitals use in situ training (training in the actual clinical environment) as a solution to meet their requirements. And commensurate with TJC’s emphasis on communications, TJC requires that drills include multidisciplinary teams. Human factors are consistently a TJC focus. 

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Operationalizing TJC's "Drill"Requirement

TJC expresses its requirement in the form of "drills" – in part so hospitals can test their systems. Here are the specific Provision of Care (PC) drill standards:

PC.06.01.01: Reduce the likelihood of harm related to maternal hemorrhage.   
Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Drills include representation from each discipline identified in the organization’s hemorrhage response procedure and include a team debrief after the drill.

PC.06.03.01: Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia.
Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.

Among the many benefits of using simulation to meet TJC’s drill requirements is that it creates a safe training environment where feedback on performance can be generated in real time and capturing data for use during a debrief is easy.

TJC does allow for other means to meet their drill requirements. But if you wish to make your drills reliable, consistent, and even mobile from place to place, simulation is an optimal solution. A patient simulator augmented by a video capture system and coupled with appropriate scenarios can deliver results that demonstrate compliance and uncover latent failures. And these same resources can be used going forward for continuous improvement efforts.

If you are someone who needs help or perhaps your organization does not have the requisite resources for simulation, Laerdal can fully support conducting simulations for you on site.

PC.06.01.01 and PC.06.03.01: 
ACOG is an important influencer

If you are debating whether to use simulation to meet TJC’s requirements, you may be interested to know of the impact that the American College of Obstetricians and Gynecologists (ACOG) has made on the development of the requirements.

TJC referred to ACOG as its foundation for PC.06.01.01 and PC.06.03.01 – and ACOG is an advocate for simulation in this arena. Given widespread agreement that simulation improves outcomes in the setting of obstetric emergencies,13 ACOG has been consistently advising its members to use simulation.14 When TJC wrote its standards, it specifically referenced ACOG’s Committee Opinion No. 590: Preparing for Clinical Emergencies in Obstetrics and Gynecology, which specifically calls for the use of simulation as a means to improve care during labor and delivery emergencies.15 

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"Drills at least annually" – why repeatability, consistency, and mobility are important

Perhaps for some, the biggest challenge in meeting TJC’s drill requirements will be the frequency of drills. Conducting drills annually is a minimum. But the true frequency will be determined by the hospitals’ assessment of proficiency.

The section below summarizes key areas where simulation has a clear role. You will gain additional benefit from simulation if you ensure that drills conducted throughout your organization – within a hospital or across a hospital system – are carried out the same way, capturing the same type of data, and meeting the same standards each time.

 

Key Takeaways

PC.06.01.01: Postpartum Hemorrhage
PC.06.03.01: Hypertensive Disorders* 

Requirement

Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Drills include representation from each discipline identified in the organization's hemorrhage response procedure and include a team debrief after the drill.

Note: This requirement is identical for PC.06.01.01: Postpartum Hemorrhage and PC.06.03.01: Hypertensive Disorders 

Rationale

Multidisciplinary drills give an organization the opportunity to practice skills and identify system issues in a controlled environment. It is crucial to involve members from as many disciplines identified in the organization's response procedure as possible. This is crucial for identifying weaknesses in the response system. A multidisciplinary approach will afford you the ability to test each level of an emergency and identify areas for improvement. Organizations should assess their level of proficiency to determine how often drills should be performed; organizations that have reached a high level of mastery may need less frequent drills. 
 
Note: This requirement is identical for PC.06.01.01: Postpartum Hemorrhage PC.06.03.01: Hypertensive Disorders 

Key Takeaways

Drills at least annually, preferably in situ

Goals:

  • To determine system issues as part of a quality improvement effort
  • To practice skills
  • To test levels of emergency preparedness
  • To identify areas for continuous improvement
  • Hemorrhage Team members need to be present*

Drill must include team debrief

Frequency is determined by hospitals' assessment of proficiency16

*Drills for Hypertensive Disorders do not require that the Hemorrhage team be present. 

One of the greater challenges that an organization faces in the context of any training is maintaining a historical record. How does someone demonstrate that training during one period reflects the same standards as training from another period? Perhaps you have dealt with this. Personnel change, performance records may not be available – there can be any number of reasons for variation from time to time or place to place. A computer-driven, simulator-based experience eliminates many of those concerns.

Some steps to incorporate simulation into your efforts

If you’re still struggling to meet TJC’s requirements, or you need to accelerate your efforts, here are some general tips to help.

Identify your goal and desired outcome 
Create a statement of what you want to physically accomplish and by when. It can be as simple as "I must train X number of labor and delivery teams annually between Y and Z date."

Your desired outcome should be what you want participants to carry back to their roles and what you want the results of their performance to be.

Create an interdisciplinary team
Based on TJC standards, you should consider involving OB/GYN doctors and nurses from your Labor and Delivery Department, but also members from your anesthesia department, pharmacy, blood bank, and emergency response/code team. Using simulation for your drills will give them all a focal point to rally around.

Involve stakeholders
Simulation can be new to people, especially those in administration. Get them involved. Let them see a simulation and how teams respond during and after the experience. If you have to prove Return on Investment with stakeholders, you may want to consider reading our article, 7 Steps to Navigating the ROI Discussion: Making the Case for Medical Simulation
 
Identify the protocols that are in place and that you must test
TJC’s drill requirements are that you not only enable staff to practice skills but that you also use the drills to determine system issues, test levels of emergency preparedness, and identify areas for continuous improvement - all with the right people present.  Use the protocols - and hopefully the environment - that you have in place. Discuss whether you accomplished the goals outlined within those protocols during your debrief.
 
Involve quality and risk management
Healthcare facilities spend millions of dollars on quality and risk management efforts each year. And hospitals employ a significant number of people to shepherd quality and risk management programs. Simulation may be a new type of intervention for them. Involve them, and you may find a new level of support. 

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Laerdal Can Help

If you are involved in Labor and Delivery in any way, you work in one of the most consistently valued and needed areas of healthcare. Meeting TJC’s Perinatal Standards are an opportunity for you to use simulation in a way that can ensure your compliance and give you a new level of empowerment for your perinatal patient safety efforts going forward. Please let us know how we can help. Contact your Laerdal representative today.

Our mission at Laerdal is helping save lives. One of the ways we pursue that mission is to ensure that clients can use simulation-based training and education to prepare their staff to deliver the best possible patient outcomes regardless of the acuity of the case. Our goal is to help save an additional 1 million lives annually by the year 2030.

References

  1. Zendejas, B., Brydges, R., Wang, A. T., & Cook, D. A. (2013). Patient outcomes in simulation-based Medical Education: A systematic review. Journal of General Internal Medicine, 28(8), 1078–1089. https://doi.org/10.1007/s11606-012-2264-5
  2. Centers for Disease Control and Prevention. (2022). Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
  3. Ibid.
  4. Centers for Disease Control and Prevention. (2022). Pregnancy mortality surveillance system. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
  5. The Joint Commission. (2019). R3 Report issue 24 PC standards for maternal safety. Retrieved from https://www.jointcommission.org/standards/r3-report/r3-report-issue-24-pc-standards-for-maternal-safety#.YvEVg3bMKUl
  6. Centers for Disease Control and Prevention. (2022). See reference #2.
  7. Wang, W., Xie, X., Yuan, T., Wang, Y., Zhao, F., Zhou, Z., & Zhang, H. (2021). Epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and National Levels: A population‐based study. BMC Pregnancy and Childbirth, 21(1). https://doi.org/10.1186/s12884-021-03809-2
  8. Lo, J. O., Mission, J. F., & Caughey, A. B. (2013). Hypertensive disease of pregnancy and maternal mortality. Current Opinion in Obstetrics & Gynecology, 25(2), 124–132. https://doi.org/10.1097/gco.0b013e32835e0ef5
  9. James, A. H., Federspiel, J. J., & Ahmadzia, H. K. (2022). Disparities in obstetric hemorrhage outcomes. Research and Practice in Thrombosis and Haemostasis, 6(1). https://doi.org/10.1002/rth2.12656
  10. Dingley C, Daugherty K, Derieg MK, et al. Improving Patient Safety Through Provider Communication Strategy Enhancements. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43663/
  11. CRICO Strategies. (2011). Annual Benchmarking Report: Malpractice Risks in Obstetrics. Retrieved from https://cdn2.hubspot.net/hubfs/217557/Documents%20-%20CBS%20Report%20PDFs/OB%202010.pdf
  12. The Joint Commission. (2019). See reference #5.
  13. Crofts, J. F., Winter, C., & Sowter, M. C. (2011). Practical simulation training for Maternity Care-where we are and where next. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 11–16. https://doi.org/10.1111/j.1471-0528.2011.03175.x
  14. The American College of Obstetricians and Gynecologists (ACOG). (2021). Simulations Working Group. Retrieved from https://www.acog.org/education-and-events/simulations/about
  15. The American College of Obstetricians and Gynecologists (ACOG). (2014). Preparing for Clinical Emergencies in Obstetrics and Gynecology: Committee Opinion Number 590. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/03/preparing-for-clinical-emergencies-in-obstetrics-and-gynecology
  16. Lerner, V., & Bajaj, K. (2021). Getting ready for 2021 Joint Commission Perinatal standards. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, Publish Ahead of Print. https://doi.org/10.1097/sih.0000000000000621

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