Illinois 2025 Birthing Hospital Quality Designation Program Criteria
1. Actively participate with ILPQC
| Criteria | Tier 1 | Tier 2 |
|---|---|---|
| Submit BE and PVB Sustainability Plans to ILPQC | Submit Sustainability Plans to ILPQC for BE and PVB (if your hospital did not participate in BE or PVB you do not need to submit a plan for the initiative your hospital did not participate in) | Submit Sustainability Plans to ILPQC for BE and PVB (if your hospital did not participate in BE or PVB you do not need to submit a plan for the initiative your hospital did not participate in) |
| Attend monthly webinars (Sustainability, Perinatal Mental Health and PVB Coaching when applicable) between January and September 2025 | Attendance at 6 or more | Attendance at 5 or more |
| Attend in-person meetings | Attendance of a provider and nurse champion at ILPQC face to face meeting and ILPQC annual conference | Attendance of a provider or nurse champion at ILPQC face to face meeting and ILPQC annual conference |
| Submit data between January and September 2025 with no more than a quarter lag | 9 months of data | 8 months of data |
| Share data with your clinical staff | Implementation of a strategy to share quality improvement (QI) data progress with clinical staff (e.g. post data, share QI progress in provider meetings/grand rounds, etc.) | Implementation of a strategy to share quality improvement (QI) data progress with clinical staff (e.g. post data, share QI progress in provider meetings/grand rounds, etc.) |
| Collect race, ethnicity, and language data | Optimize collection of race, ethnicity and language data | Optimize collection of race, ethnicity and language data |
| Stratify data by race, ethnicity, and insurance status | Stratification of designated measures by race, ethnicity and insurance status with plan for data review and action to address identified disparities | Stratification of designated measures by race, ethnicity and insurance status with plan for data review and action to address identified disparities |
| Participate in quality improvement support | Attend 1 or more quality improvement support contact with ILPQC per year | Attend 1 or more quality improvement support contact with ILPQC per year |
2. Educate clinical teams (both tiers)
- Provide clinical team education yearly and for new hires that addresses patient experience of care with a focus on reducing disparities, such as:
- Unconscious bias (implicit bias)
- Respectful care Trauma – informed care
- Shared decision-making
- Reducing stigma and/or
- Active listening
3. Engage patients and community (both tiers)
- Engagement of a patient partner in the quality improvement team
- Hold 2 or more respectful care breakfasts per year
- Coordinate quality improvement efforts to engage outpatient prenatal clinics, federally qualified health centers and other community health clinics affiliated with your hospital
- Build relationships with community-based doulas, home visiting programs and other community resources in your hospital catchment to create points of access to improve referral of patients to these community resources
- Review labor and delivery policies and procedures to promote doula-friendly unit culture and strategies to support doula participation in the maternity care team
- Implement patient reported experience measures (“PREM”) Survey for patient survey on respectful care for 10% or more of deliveries per month or at least 15 deliveries per month
4. Achieve aims and reduce disparities (3 out of 3 for Tier 1, 2 out of 3 for Tier 2)
- Achieve healthy people nulliparous, term, singleton, vertex (NTSV) cesarean rate of ≤ 23.6%
- Achieve ≤ 25% NTSV cesarean rate for all stratified groups (race, ethnicity, insurance status)
- Link ≥ 70% of patients who screen positive for social determinant of health needs to community resources