Authority: IC 16-21-13-5

Affected: IC 16-21-13

Sec. 4. Each delivering facility shall meet the following requirements for performance improvement:

1. (1) Have a multidisciplinary continuous quality improvement program for improving maternal and neonatal health outcomes that has initiatives to promote patient safety including, but not limited to, the following:

   1. (A) Safe medication practices.
   2. (B) Universal protocol to prevent procedural errors.
   3. (C) Educational programs to improve communication and team work.

2. (2) Conduct internal perinatal case reviews that include all of the following:

   1. (A) Maternal deaths.
   2. (B) Intrapartum fetal and neonatal deaths.
   3. (C) Maternal and neonatal transports.

3. (3) Utilize a multidisciplinary forum to conduct periodic performance reviews of perinatal programs. This review shall include the following:

   1. (A) A review of the following:

      1. (i) Trends.
      2. (ii) Deaths.
      3. (iii) Transfers.
      4. (iv) Very low birth weight infants.
   2. (B) Problem identification and solutions.
   3. (C) Issues identified from the quality management process.
   4. (D) Systems issues.

(Indiana Department of Health; 410 IAC 39-6-4; filed Aug 14, 2019, 3:32 p.m.: 20190911-IR-410180416FRA; readopted filed Nov 14, 2025, 11:18 a.m.: 20251210-IR-410240588RFA)