Designations

The designation levels are based on meeting the milestone criteria per established frequency over a 12-month period, starting with the April 2024 through March 2025 implementation period. Designations will be initiative-specific, meaning milestones cannot be “mixed-and-matched” if a PA PQC Healthcare Team is participating in multiple initiatives. Initiatives in sustainment are not eligible for designation. Designation recognition will include a PA PQC banner, a graphic for sites to display on their website, and being listed on the PA PQC website by Designation category, celebrating the hospital’s achievement.

Achievement: Established multidisciplinary teams that have demonstrated improvements in maternal and newborn care by sharing best practices and data in their hospital and community, with a proven commitment to health equity and patient participation in their quality improvement work. Criteria: QI Participation, Patient Voice, AND Health Equity

Achievement: Established multidisciplinary teams that have demonstrated improvements in maternal and newborn care by sharing best practices and data in their hospital and community, and are dedicated to incorporating patient voice or health equity in their quality improvement work. Criteria: QI Participation plus EITHER Patient Voice OR Health Equity

Achievement: Established multidisciplinary teams that have demonstrated improvements in maternal and newborn care by sharing best practices and data in their hospital and community. Criteria: QI Participation

Designation Criteria:

QI Participation: Meet milestones listed below and maintain a minimum of two “qualifying quarters” for the same initiative during the designation year (April 2024 – March 2025). A “qualifying quarter” is defined as a single quarter in which the milestones are all met for a specific initiative (milestones 1 and 5 are completed at the hospital level and therefore only need to be completed ONCE per quarter per hospital, regardless of the number of initiatives joined).

Patient Voice: Show proof of including lived experience voices in PA PQC quality improvement work by implementing one or more community and patient partnership interventions. (See list below of patient voice intervention examples).

Health Equity: Show proof of health equity interventions in PA PQC quality improvement work that demonstrate a commitment to narrowing the equity gap. (See the list below of patient voice intervention examples).

 Health Equity and Patient Voice Reporting:

• Work with your QI coach to determine an eligible intervention (see examples below) to meet the health equity or patient voice criteria.
  • The intervention needs to be actively worked on during the designation period (April 2024 through March 2025).
• If you would like to be considered for Silver or Gold-level designation, you will need to turn in a QI plan for your equity and/or patient voice intervention to your coach by June 30, 2024, and show proof of your equity and/or patient voice intervention through a survey* by March 30, 2025. The “proof” will be evaluated by PA PQC staff based on the plan to determine whether the QI work meets the criteria.

*Additional details on the survey will be forthcoming.

Examples of Patient Voice Interventions:
Patient Voice Involvement with Staffing
Examples might include:

• Facility has a budget for compensating those with lived experience for their time and a process in place for prompt payment
• Facility has specific job descriptions for those with lived experience
• Facility includes patient voice in hiring process for key roles in organization

Mechanism for Patients/Family to Provide Feedback that Leads to Tests of Change
Options could include follow-up phone calls after discharge or patient satisfaction survey. Additionally, those with lived experience could sit on work groups, committees, or attend regular meetings of the quality improvement team.

Staff Training in Family-Centered Care
Examples of some of the required training elements:

• Patients are partners in their decision-making with healthcare providers and staff
• Delivery of reliable, evidenced-based patient education
• Transparency between nurses/providers and the pregnant person and their family/partner
• Birth parents and babies should stay together (rooming in)
• Labor support encouraged (doula, freedom of movement, birthing plan)

Optimize Unit and Organization for Patient Partnership
Examples of some of the required elements:

• System in place for leadership to seek input from staff and community and integrate feedback into decision-making
• Facility has written, internal structure for addressing incorporation of patient voice

Examples of Equity Interventions:
Addressing Health Equity Training for Nurses and Providers
Provider training includes physicians and advance practice providers. Examples of some of the required training elements may include:

• Identification of disparities in care and how disparity impacts maternal and infant health outcomes
• How to decrease health disparities at the interpersonal and facility levels
• Historical sources of health disparities
• How to effectively communicate and establish transparency across identities, including racial, ethnic, religious, geographic, and gender identities
• Case studies that highlight the impact of health disparities and how they might be addressed

Optimize Unit and Organization for Health Equity
Examples of some of the required elements:

• Facility- and system-level performance indicators are disaggregated by race/ethnicity and other relevant indicators and are shared with staff and community
• Unit performance measures are disaggregated by race/ethnicity and other relevant categories and are shared with providers and staff
• Facility has written, internal structure for addressing issues related to health disparities
• Staff job descriptions and competencies include expectations related to health equity and disparities

Implement Validated Tool to Measure Respectful Care
Completion of one of the following respectful care assessments, in its entirety/unedited version, by a percent of birthing persons and subsequent tests of change identified by PA PQC team. Examples include:

• Mothers Autonomy in Decision Making Scale
• Mothers on Respect Index
• Mistreatment Index

Implement Equity Pause During Multidisciplinary Debriefs
An “equity pause” is a designated time to pause during debriefs to directly ask about issues related to equity and bias.

Use Data Stratification to Improve Health Disparities
Stratifying data by race and ethnicity is one way of ensuring processes are applied equitably and that those processes result in equitable outcomes. Data stratification itself is not equity, but using stratified data to make strategic decisions, develop tests of change, and address inequities is. Facilities must:

• Report stratified race/ethnicity data for all process measures allowed through Life QI
• Review data with facility leadership and/or senior sponsor at least quarterly
• Share stratified data with providers and staff at least quarterly
• Develop a plan to address inequities identified through stratification process
• Develop a plan to share stratified data with patients and the community you serve

Please send all PA PQC-related press releases in advance to This email address is being protected from spambots. You need JavaScript enabled to view it. for review, and please notify the PA PQC if your organization is contacted by the media about your participation in the PA PQC.