13-073 Code Vt. R. 13-140-073-X - MATERNAL MORTALITY REVIEW PANEL RULE

Section 1.0 Authority

This rule is adopted under the authority pursuant to 18 V.S.A. § 1556.

Section 2.0 Purpose

This rule provides procedures for gathering and reporting information relating to maternal deaths to the Maternal Mortality Review Panel created by 18 V.S.A. Chapter 30.

Section 3.0 Definitions

3.1 "Commissioner" means the Commissioner of the Vermont Department of Health.

3.2 "Individually identifiable information" means information that includes vital records; hospital discharge data; prenatal, fetal, pediatric, or infant medical records; hospital or clinic records; laboratory reports; records of fetal deaths or induced terminations of pregnancies; and autopsy reports.

3.3 "Department" means the Vermont Department of Health.

3.4 "Facilities" means health care providers, health care facilities, clinics, laboratories, medical records departments and state offices, agencies and departments.

3.5 "Maternal mortality" or "maternal death" for this rule and as defined in 18 V.S.A. § 1551 means:

3.5.1 "Pregnancy-associated death" means the death of a woman while pregnant or within one year following the end of pregnancy, irrespective of cause.

3.5.2 "Pregnancy-associated, but not pregnancy-related death" means the death of a woman while pregnant or within one year following the end of pregnancy due to a cause unrelated to pregnancy.

3.5.3 "Pregnancy-related death" means the death of a woman while pregnant or within one year following the end of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes.

3.6 "MMRP" means the Maternal Mortality Review Panel.

Section 4.0 Identification and Reporting Maternal Deaths

4.1 Facilities shall identify and report maternal deaths to the Department.

4.2 Maternal deaths may be identified and reported to the Department through the following sources:

4.2.1 Direct report from facilities;

4.2.2 Data linkage through a death certificate;

4.2.3 Case finding reported by a MMRP member;

4.2.4 Medical examiner's report.

4.3 For maternal deaths identified and reported in 4.2.1 above, the facilities shall complete and send the Department's Maternal Death Form to the Department either by secure fax, electronic or paper format within 10 business days of a maternal death.

4.4 For deaths identified in 4.2.2-4.2.4 the Department will complete the Maternal Death Form.

4.5 A hospital reporting under this rule is still required to report an adverse event under 18 V.S.A. Chapter 43A, Patient Safety Surveillance and Improvement System.

Section 5.0 Program Access to Health Information

5.1 Upon receipt of a written request from the Commissioner stating that there is a public health risk, a facility shall provide the following information to the Department:

5.1.1 Individually identifiable information which shall be provided in a format specified by the Department;

5.1.2 A root cause analysis of the event if one has been completed.

5.2 The information shall be reported within sixty (60) days of the request.

Section 6.0 MMRP Access to Health Information

6.1 The Department shall prepare and present to the MMRP a de-identified case summary of each maternal death reported or identified based on the following:

6.1.1 Information received from the reporting facilities;

6.1.2 Family interview as applicable;

6.1.3 The facility's root cause analysis of the event if one has been completed.

6.2 All members of the MMRP shall sign a confidentiality agreement regarding case review conduct and assurances of confidentiality as soon as practicable after their appointment to MMRP.

Section 7.0 Contact with Families

7.1 If the MMRP finds the records provided are insufficient to assess the circumstances and factors associated with the decedent's death, the MMRP may request that the Commissioner or the Commissioner's designee contact the family in writing for additional information.

7.2 Initial family contact shall occur through a letter from the Department to include the following information:

7.2.1 An invitation for the family to participate in a home or office interview through a voluntary process;

7.2.2 The purpose of the interview and an explanation of how the information will be used;

7.2.3 That the information obtained shall be used to determine and understand the significant social, economic, cultural, safety and health care delivery system factors that are associated with maternal mortality;

7.2.4 The information obtained shall be confidential and the name of the deceased mother, names of her family, and any other individually identifying information shall not be released to the public;

7.2.5 The family may choose to delay the contact or decline participation.

Notes

13-073 Code Vt. R. 13-140-073-X

STATUTORY AUTHORITY: V.S.A. 801(b)(11) and 18 V.S.A. § 1556
EFFECTIVE DATE: July 3, 2014 Secretary of State Rule Log #14-023