TJC’s New Perinatal Safety Standards

TJC’s New Perinatal Safety Standards

Each year approximately 700 women die from pregnancy-related complications, and according to the CDC, three out of five of those deaths are preventable. There is evidence that approximately 20% of postpartum hemorrhage occurs in women without any risk factors. To combat these statistics and improve perinatal care, The Joint Commission (TJC) has issued the new Perinatal Safety Standards to guide hospital policies and procedures. The new standards, in effect as of July 1, 2020 will require the use of evidence-based tools for determining maternal hemorrhage, as well as the repeated monitoring of blood pressure.

To properly care for this patient population, L&D staff need to be knowledgeable of the new perinatal safety standards and should be prepared to answer questions about these protocols during TJC surveys (including the ability to discuss which evidenced-based information is utilized).


TJC indicates that documentation is required to ensure Elements of Performance are being met (PC.06.01.01 EP 2, PC.06.03.01 EP 1,2). Documentation is often the greatest opportunity for organizations to demonstrate their compliance. Conversely, it can be very challenging and time consuming during a survey if staff members are not able to efficiently present a surveyor with documentation that verifies compliance.

Some points to consider include:

  • Make sure documentation supports a focus on the patient’s perception of the effectiveness of care rendered, and ensure this is reflected in documentation (PC.01.02.01 EP 1).
  • Nursing assessments and reassessments must have defined time-frames (PC.01.02.03 EP 1).
  • Make sure there is a written policy that defines the scope and content of nursing assessments and reassessments (PC.01.02.01 EP 1). Surveyors will review for policy documentation and compliance.
  • When a protocol is implemented, ensure all elements are documented (RC.02.01.01 EP 2). Many Electronic Medical Health Records (EHMR) contain multiple points to enter documentation, and it is recommended that organizations work to standardize their documentation procedures.

Emergency Medications

The new perinatal safety standards stress that emergency medications should be readily available in the event of an emergency (MM.03.01.03 EP 1). Surveyors will review your organization’s approved medications for postpartum hemorrhage (PPH) and eclamptic seizure emergencies. Proper medication storage includes the removal and replacement of medications upon expiration. Best practice is to include a visual showing the expiration on the front of the cart of the first medication, or to supply expiration dates as a reminder to staff of when to replace items. Surveyors will review for oversight of this activity (MM.03.01.03 EP 6). Checklists are proven to be helpful, as they are designed to reduce errors and ensure consistency in practice. Medication management was a focus for TJC in their 2019 Hospital Executive Briefing (read our summary).

A standardized, secured, and dedicated hemorrhage supply kit should be available. All staff should be aware of the location of this kit. Be sure to review the manufacturer’s guidelines to ensure proper storage of supplies placed in these kits.

Emergency Department Preparedness

Take care not to overlook the need for perinatal preparedness in the ED. Ask yourself:

  • If a patient presents to the Emergency Department in crisis, how are staff trained to care for the patient?
  • Are there also standardized protocols that apply to the ED?
  • Are the ED staff a part of the emergency drill and simulation?

Blood Protocol

Under the new perinatal safety standards, surveyors will review the Massive Transfusion Policy (MTP), and staff must be able to discuss the implementation of this policy. Early availability of optimal blood is necessary to maintain organ perfusion and oxygenation.

Areas of MTP that staff should understand include:

  • When, how, and by who is the organization’s MTP activated?
  • Who can transport blood?
  • What is the procedure for multidisciplinary drills and how often they occur?
  • What is the procedure for obtaining additional blood if it is needed?

Staff Education and Training

Surveyors will also assess staff education and training. All staff and providers who treat pregnant and postpartum patients should be educated minimally every two years or whenever changes to procedure occur. This includes onboarding new staff. Often surveyors will request staff names to be added to the Competency Assessment Session. During this session staff files are reviewed for training and education, record of orientation of new staff, license, and verification (HR.01.01.01 EP 2) (HR.01.06.01 EP 1). The hospital should review staff job descriptions to ensure that they match their on-the-job responsibilities. This standard requires that staff evaluation be completed once every three years, or more frequently as may be required by the organization (HR.01.07.01 EP 1,2). Organizations are surveyed for their policy. Competencies that may be evaluated include Quantitative Blood Loss (QBL), fetal monitoring, and annual emergency drills.

Ensure that patient discharge instructions are included in the patient’s medical record. These instructions should contain education regarding the signs and symptoms of postpartum hemorrhage and severe hypertension/preeclampsia and alert the patient to seek immediate care if they should occur after discharge (PC.04.01.05 EP 7). The staff approach to training should ensure that the patient is ready to learn, and that a learning needs assessment is completed. For example, consider what the patient’s preference for learning is and examine limitations or barriers. (PC. 02.03.01 EP 1). Ensure the organization provides information in a manner tailored to the patient’s age, language, and ability to understand (RI.01.01.03 EP 1).

Tips for Survey Success

TJC surveyors will typically seek to interview front line staff because they have the most patient interactions. Staff interviews are a great way to demonstrate that an organization has operationalized the new standards. By reviewing policies with staff prior to the survey, they can help demonstrate compliance by exhibiting personal knowledge of policy and the new standards. Staff should also have knowledge of which evidence-based information is being utilized to determine policies.

You can help keep your survey fluid and efficient by ensuring front line staff can navigate through advanced the EHR. If staff members cannot efficiently present a surveyor with documentation, it appears they are unfamiliar and that the organization’s practices aren’t standard.

And finally, on the day of your survey remember to breathe and relax. Your staff members are the experts, and because you have prepared properly, they should remain confident.


OB Hemorrhage Toolkit 2.0 (California Maternal Quality Care Collaborative)

Patient Safety Bundles: Obstetric Hemorrhage (Council on Patient Safety in Women’s Health Care)

Postpartum Hemorrhage Project: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Poster Download: Postpartum Hemmorhage Collaborative (The PPH Project)

Download: Patient Information – Speak up for your Safety (Clinical Center, National Institutes of Health)

Need Help?

To discuss how TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment, contact us at (800) 241-0142 or for a consultation.


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