Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 640 - REGIONALIZED PERINATAL HEALTH CARE CODE › Appendix G - Sample Letter of Agreement

Current through Register Vol. 48, No. 28, July 12, 2024
_________________
(name of
				Administrative Perinatal Center) is recognized and designated by the Illinois
				Department of Public Health as a Level III Administrative Perinatal Center
				providing obstetrical and neonatal care. In order to serve as a Non-Birthing
				Hospital, Level I, II, II with Extended Neonatal Capabilities or III,
				affiliated with an Administrative Perinatal Center designated by the Illinois
				Department of Public Health,
__________________
(name
				and address of hospital) agrees to affiliate with the above Administrative
				Perinatal Center.
This agreement is consistent with the Illinois Department of
				Public Health, Regionalized Perinatal Health Care Code (77 Ill. Adm. Code
				640).
Components for Letter of Agreement
I. Introductory Remarks: The Administrative Perinatal Center
				may list items of organization of the Center.
II. Administrative Perinatal Center Obligations
A. A 24-hour obstetrical and neonatal "hot-line" for
				immediate consultation, referral or transport of perinatal patients is
				available.
Obstetrical
Neonatal
Hospital
Telephone #
Hospital
Telephone #
B. The Administrative Perinatal Center shall accept
				all medically eligible obstetrical/neonatal patients.
C. If the above named Administrative Perinatal
				Center is unable to accept a referred maternal or neonatal patient because of
				bed unavailability, that Center shall assist in arranging for admission of the
				patient to another hospital capable of providing the appropriate level of
				care.
D. Transportation of neonatal patients remains the
				responsibility of the Administrative Perinatal Center. Decisions regarding
				transport and mode of transport will be made by the Administrative Perinatal
				Center neonatologist in collaboration with the referring health care
				provider.
E. Transportation of the obstetrical patient remains
				the responsibility of the (Level I, Level II, Level II with Extended Neonatal
				Capabilities or Level III hospital). Decisions regarding transport, transfer
				and mode of transport or transfer shall be made by the Administrative Perinatal
				Center maternal-fetal medicine physician in collaboration with the referring
				health care provider.
F. The maternal-fetal medicine physician of the
				Administrative Perinatal Center, in collaboration with the referring health
				care provider, shall decide whether to have an obstetrical patient stabilized
				before transfer, kept in the affiliated unit or transferred immediately. The
				best possible alternatives and the staff needed for transport shall be
				determined.
G. The Administrative Perinatal Center shall
				distribute written protocols for the mechanism of referral/transfer/transport
				to the affiliated hospital physician, administration and nursing service.
				Protocols are to include a mechanism for data recording of the time, date and
				circumstances of transfer so that this information can be part of the morbidity
				and mortality reviews. (See Appendix A.)
H. The Administrative Perinatal Center shall send a
				written summary of patient management and outcome to the referring health care
				provider of record and to the hospital.
I. The Administrative Perinatal Center shall conduct
				quarterly mortality and morbidity conferences at __________________________
				Hospital.
1. The Administrative Perinatal Center's Perinatal
				Network Administrator, maternal-fetal medicine physician, neonatologistand/or
				obstetrical and neonatal nurse educators shall conduct the conference.
2. ______________________ Hospital shall prepare
				written summaries of cases and statistics for discussion, to be available to
				the Administrative Perinatal Center at least one week prior to the
				conference.
3. The Regional Quality Council of each Regional
				Perinatal Network shall determine the content of the review. The review shall
				include, but not be limited to, stillbirths, neonatal deaths, maternal and/or
				neonatal transports.
J. The Administrative Perinatal Center shall
				transfer patients back to the referring hospital when medically feasible, in
				accordance with physician to physician consultation.
K. The Administrative Perinatal Center shall develop
				and offer Perinatal Outreach Education programs at a reasonable cost to include
				the following:
1. On-site consultation by Administrative Perinatal
				Center physicians and nurse educators as needed.
2. Periodic obstetrical and neonatal needs
				assessment of ______________ Hospital.
3. Provide __________________ Hospital with
				protocols for patient management.
4. Develop Continuing Medical Education programs for
				obstetricians, pediatricians and family practitioners either at
				__________________ Hospital or at the Administrative Perinatal Center
				site.
5. Mini-Fellowships at the Administrative Perinatal
				Center for __________________ Hospital physicians and nurses.
6. Programs based on needs assessment by outreach
				nurse educators at __________________ Hospital for obstetrical and neonatal
				nursing staff.
L. The Administrative Perinatal Center shall
				establish, maintain and coordinate the educational programs offered for all
				Non-Birthing Centers, Level I, Level II, Level II with Extended Neonatal
				Capabilities, and Level III hospitals that it serves.
M. The Administrative Perinatal Center shall develop
				a Regional Quality Council, including, but not limited to, representatives of
				each hospital in the Regional Perinatal Network. This group shall meet at least
				quarterly to plan management strategies, evaluate morbidity and mortality
				reviews, evaluate the effectiveness of current programs and services and set
				future goals. The Regional Quality Council shall determine the data collection
				system to be used by the Regional Perinatal Network.
III. __________________ Hospital Obligations
A. __________________ Hospital shall utilize the
				"hot-line" established by the Administrative Perinatal Center for consultation,
				referral and transport.
B. __________________ Hospital shall transfer to
				__________________ Administrative Perinatal Center obstetrical and neonatal
				patients who require the services of the Administrative Perinatal Center,
				including, but not limited to, patients outlined in the Regionalized Perinatal
				Health Care Code.
C. __________________ Hospital (level of care) shall
				usually care for the following maternal and neonatal patients.
D. __________________ Hospital shall develop an
				ongoing in-house continuing educational program for the obstetrical and
				neonatal medical staff and other disciplines as needed.
E. __________________ Hospital shall participate in
				continuing educational programs for both nurses and physicians developed by the
				__________________ Administrative Perinatal Center. Cost to be shared.
F. __________________ Hospital shall designate
				representatives to serve on the __________________ Regional Quality
				Council.
G. __________________ Hospital shall establish a
				Perinatal Development Committee composed of medical and nursing representatives
				from both neonatal and obstetrical areas, administration and any other
				individuals deemed appropriate.
H. __________________ Hospital shall maintain and
				share such statistics as the __________________ Regional Quality Council may
				deem appropriate.
I. __________________ Hospital shall develop or to
				utilize programs at __________________ Administrative Perinatal Center for
				follow-up of neonates with handicapping conditions.
IV.
Joint Responsibilities
A. This agreement will be valid for three years, at
				which time it may be renewed or re-negotiated.
B. If either __________________ Hospital or the
				__________________ Administrative Perinatal Center wishes to change an
				individualized portion of this agreement, either may initiate the discussion.
				If a change in the agreement is reached, the change must be reviewed by the
				Department. If the __________________ Hospital wishes to make a change and
				__________________ Administrative Perinatal Center is not in agreement,
				__________________ Hospital can request a hearing by the Department.
C. If any of the institutions wants to terminate the
				agreement, written notification shall be given to the Department and other
				participating institutions six months in advance.