Complaints; quality assurance – Ohio Admin. Code 3701-7-15

Each maternity unit, newborn care nursery, or maternity home must document complaints regarding the quality or appropriateness of services and include the following information:

• The date complaint was received;
• The identity, if provided, of the complainant;
• A description of the complaint allegations;
• The identity of persons, or provider of the services, or both, involved;
• The findings of the investigation; and
• The resolution of the complaint.

Each maternity unit or newborn care nursery must establish a quality assessment and improvement program, which must do all the following:

• Monitor and evaluate all aspects of care including effectiveness, appropriateness, accessibility, continuity, efficiency, patient outcome, and patient satisfaction;
• Establish expectations, develop plans, and implement procedures to assess and improve the quality of care and resolve identified problems;
• Establish expectations, develop plans, and implement procedures to assess and improve governance, management, clinical and support processes;
• Establish information systems and appropriate data management processes to facilitate the collection, management, and analysis of data needed for quality improvement;
• Internally document and report findings, conclusions, actions taken, and the results of any actions taken to the health care service’s management and medical director;
• Document and review all unexpected complications and adverse events, which arise during the provision of the service or during the hospital stay; and
• Hold regular meetings, chaired by the medical director or designee within sixty days after a death or complication, to review all deaths and complications and to report findings. Any pattern that might indicate a problem shall be investigated and remedied, if necessary.

Each maternity unit, newborn care nursery, and maternity home must report the following information to the department:

• Infant death during the course of admission through delivery;
• Maternal death through the mother’s admission and care at the delivering hospital;
• Infant abduction; and
• Discharge of an infant to the wrong family or organization.