Section 640.APPENDIX K   Elements for Submission for Designation, Redesignation or Change in Designation

Level III Review

•           Appendix A

•           Resource Checklist for Level III

•           Evaluation letter from Administrative Perinatal Center

•           Vita for co-directors

•           Credentials for  Obstetric (OB)/Family Practice (FP) physicians, Advance Practice Nurses (APN), Neonatology & Anesthesia

•           Copy of OB/Peds Departmental Rules

•           Maternal-Fetal Medicine (MFM), Neonatology Consultation/referral tool/QA reports for 3 months

•           Mortality and Morbidity (M&M) statistics and description of the process/participation

•           Transport statistics, both into and out of hospital

•           Listing of educational classes

•           Description of educational classes

•           Description of CQI

•           3 months of call schedules for OB, Maternal-Fetal Medicine and Neonatology (current and last 2 actual or 3 proposed schedules)

Level II with Extended Neonatal Capabilities Review

•           Appendix A

•           Resource Checklist for Level II with Extended Neonatal Capabilities

•           Evaluation letter from Administrative Perinatal Center

•           Vita for Director of Neonatology, Maternal-Fetal Medicine (MFM), if appropriate

•           Credentials for Obstetricians/Family Practice  physicians, Advanced Practice Nurses (APN), Neonatology & Anesthesia

•           Copy of OB/Peds Departmental Rules

•           Consultation/referral tool/QA reports for 3 months

•           Mortality and Morbidity (M&M) statistics and description of process/participation

•           Transport statistics, both into and out of hospital

•           Listing of educational classes

•           Description of CQI

•           3 months of call schedules for OB, MFM and Neonatology as appropriate

Level II Review

•           Appendix A

•           Resource Checklist for Level II

•           Evaluation letter from Administrative Perinatal Center

•           Credentials for Obstetrics (OB)/Family Practice (FP) physicians, Advance Practice Nurses (APN), Neonatology & Anesthesia

•           Copy of OB/Peds Departmental Rules

•           Consultation/referral tool/QA reports for 3 months

•           Mortality and Morbidity (M&M) statistics and description of process/participation

•           Transport statistics − out of hospital

•           Listing of educational classes

•           Description of CQI

Level I Review

•           Appendix A

•           Resource Checklist for Level I

•           Evaluation letter from Administrative Perinatal Center

•           Credentials for Obstetrics (OB)/Family Practice (FP) physicians, Advance Practice Nurses (APNs), Neonatology & Anesthesia

•           Mortality and Morbidity (M&M) statistics and description of process/participation

•           Transport statistics − out of hospital

•           Listing of educational classes

•           Description of CQI

Administrative Perinatal Center

•           Network description

•           Educational programs

•           Network projects

•           Discussion with representatives from Regional Network Hospitals

•           Network participation

•           Network evaluation

•           Network challenges

•           Network M&M statistics

•           University integration

(Source:  Added at 35 Ill. Reg. 2583, effective January 31, 2011)