CMS targets Maternal Morbidity on a national scale

March 10, 2022

As reported in a Premier news release, the Centers for Medicare and Medicaid Services (CMS) recently finalized the new Maternal Morbidity Structural Measure aimed at ensuring the use of evidence-based best practices across the continuum of care.

Despite the work aimed at reducing America’s maternal morbidity rate, our nation continues to experience significant disparities in outcomes across populations. Maternal and infant mortality and morbidity is a complex issue. Closing the gaps will require new approaches and sustainable solutions that can be scaled nationally.

What is the new CMS Maternal Morbidity Structural Measure?

This new measure is intended to determine the number of hospitals currently participating in a state or national perinatal quality collaborative (PQC), and whether hospitals are implementing the safety practices or bundles included as part of these initiatives.

This measure is the first step toward assessing the current quality improvement initiatives and implementation of patient safety practices or bundles with the objective of reducing maternal morbidity and mortality.

Within the CMS Measures Management System, the structural measure definition states that it “assesses features of a healthcare organization or clinician relevant to its capacity to provide healthcare.” This approach to measurement focuses on the environment of care and its related administrative processes and policies. The underlying assumption is that system characteristics have a significant impact on quality of care.

How can hospitals and health systems answer ‘yes’ to this measure?

Historically, CMS structural measures do not require patient-level data collection; instead, they require answering a series of ’yes’ and ’no’ questions to report whether the hospital is participating in a specific quality initiative.

The Maternal Morbidity Structural Measure follows the same process and requires hospitals and health systems to answer a two-part question: Does your hospital or health system participate in a statewide and/or national PQC program aimed at improving maternal outcomes during inpatient labor, delivery and post-partum care and has it implemented patient safety practices or bundles related to maternal morbidity to address complications, including, but not limited to, hemorrhage, severe hypertension/preeclampsia or sepsis?”

Hospitals and health systems will need to select one of the following responses: ‘yes’, ‘no’ or ‘not applicable,’ indicating the hospital does not provide inpatient labor and delivery care.

To answer ‘yes’, the hospitals or health system must meet both parts of the question, participate in a PQC program and have implemented the safety practices.

A PQC is defined as a statewide or a multi-state network of multidisciplinary teams of perinatal healthcare providers and public health professionals working to improve maternal and infant outcomes through the implementation of quality improvement initiatives designed to continually monitor, analyze and improve the care provided.

Enter Premier’s PQC’s Hospitals and health systems participating in Premier’s Perinatal Improvement Collaborative or the Department of Health and Human Services (HHS) Perinatal Improvement Collaborative (HHS PIC) will meet CMS’s PQC definition and multi-state network requirements for the new Maternal Morbidity Structural Measure.

Premier has been working with hospitals, health systems and industry associations to improve the quality and cost of maternal care for decades. It began with the Premier Perinatal Safety Initiative (PPSI), which united a group of hospitals and helped them reduce maternal deaths and harm by 20 percent.

Alongside the PPSI, Premier’s work in CMS’s Partnership for Patients program helped Premier members avoid approximately $35 million in hospital-related costs, avoid an estimated 7,400 perinatal harm events, and reduced early elective deliveries by 69.7 percent.

In 2019, Premier and 11 hospital members launched the data-driven Perinatal Improvement Collaborative (PIC) designed to help members reach zero preventable maternal and neonatal harm and deaths.

Building on this work, Premier partnered with HHS to leverage Premier’s standardized, evidence-based data and proven performance improvement methodology to scale advancements in care for mothers and infants across the nation.

And in 2021, Premier and HHS OWH launched the HHS PIC, consisting of more than 220 hospitals and health systems across all 50 states designed to implement standardized, evidence-based practices and care bundles with collaborative members, measure outcomes to identify and scale the most effective practices.

This work will augment, align and help scale facility, state and national maternal health strategies. These collaboratives use comprehensive, detailed, standardized performance and outcome data to evaluate steps necessary to improve clinical care for both the mother and infant. They capture and integrate patient and clinical care data to understand drivers of preventable harm and death.

In addition, the collaboratives collect and evaluate the impact of social determinants of health and integrate this information into care delivery. Each hospital in the collaborative captures more than 150 measures to understand clinical and non-clinical factors that impact overall maternal and infant health outcomes aimed at reducing racial, ethnic and geographic disparities and lowering maternal and infant mortality across the nation.

Where do hospitals and health systems submit their ‘yes’ answer?

Hospitals and health systems will submit their answers using the CMS QualityNet Secure Portal (also referred to as the Hospital Quality Reporting (HQR) System).

Reporting is required for FY2023 Inpatient Quality Reporting program, and the first reporting period is Oct. 1, 2021, through Dec. 31, 2021. Hospitals will answer the questions based on their perinatal quality improvement collaborative participation during this three-month period.

Beginning with calendar year 2022 for FY2024 payment determination and subsequent years, hospitals will report the measure annually and answer the questions based on perinatal quality improvement collaborative participation during the calendar year.

Premier News Release