Improving Maternal Health- New TJC Standards: Severe Hypertension/Preeclampsia

The United States ranks 65th among industrialized nations in terms of maternal death.¹ In December 2020, Alex Azar, Secretary of Health and Human Services along with Jerome Adams, Surgeon General issued the Call to Action to Improve Maternal Health. This coupled with the release of The Joint Commission’s six new elements of performance (EP’s) under PC.06.01.03 will hopefully establish new expectations and opportunities to improve care and reduce mortality in this special population. The new Joint Commission Elements of Performance, developed by a stakeholder group comprised of experts within the OB-GYN field², took effect January 1, 2021 and focuses on early identification and provision of evidence-based care to reduce patient harm amongst pregnant women.

In summary, the new EP’s:

  •  Advise organizations to use evidence-based best practices to develop procedures for monitoring blood pressure and parameters/expectations for re-taking blood pressure. Criteria defining which patients have severely elevated blood pressure need to be included along with actions to be taken when severe hypertension is identified.
  •  Elevated blood pressure is not only a risk to the pregnant women but also to the post-partum woman. Organizations need to develop a management policy setting forth the following:
    • Defining which medications, based upon current literature must be available for emergency response to these patients. These medications need to be readily available in any location where a patient may be present. These medications can be incorporated into your emergency cart or assembled in a separate box but should be managed as defined in your emergency medication/Code Cart policy to ensure constant availability at the point of care.
    •  Guidelines for implementation of seizure prophylaxis.
    •  Process for consulting additional experts and transfer to a higher level of care when required.
    •  Criteria and process for conducting continuous fetal monitoring and ensuring this equipment is also readily available.
    •  Process for preparation for emergent delivery. How do you alert the care team of eminent delivery? How will your organization get the appropriate resources to the bedside? Will your organization implement a new Code Name for overhead paging, texting and/or alerting?
    •  Establishing a process that creates the opportunity for the care team to debrief on what worked, what didn’t work and what could have been done better.

The elements of performance continue and further set forth:

  • The expectation for role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/preeclampsia procedure must be provided to those who may render care to these patients. This would include Emergency Department staff even if your organization does not offer birthing services. Education on this topic and management program is expected to occur at orientation, whenever the procedure changes, or once every two years. Remember, this education is for the care team, so make certain you establish a process for your medical staff to be educated inclusive of medical students, interns, and residents.
  •  Education is the process whereby we convey information. Information without the ability to apply it is useless, so TJC expects that drills will be performed, at least annually, in all areas where this type of patient can be present. The drill process will allow the organization to identify any system issues and proactively make improvements to the care processes. Using the debriefing process after drills is essential to identifying where improvement can occur and is an expectation with the elements of performance.
  •  Continuing with embedding the principles of process improvement into the standards, the Elements of Performance advise that the organization needs to establish criteria that set forth when case review and/or peer review would be undertaken and adhere to their criteria. This criterion should be developed by the medical staff and incorporated into your case review, peer review and/or incident review policies.
  •  Last but not least, engaging and educating the patient and other care givers/support persons on the following is essential to early detection and on-going care. Element of Performance 6 requires organizations to:
    •  Provide printed education to patients. Remember that this printed education needs to be provided in the language identified by the patient as their preferred language. Also ensure that you have a means to convey this education to those with other types of disabilities.
    •  There are three key topics that need to be addressed within the educational materials:
      •   Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care. The patient and support person(s) should be instructed and encouraged to immediately notify the care team if any of these signs/symptoms appear. Taking a moment to review with the patient and support person how to use the call bell, or how to contact the staff is vital and reassuring to the patient.
      • Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care. This instruction should also advise the patient as to how to seek immediate care.
      • When to schedule a post-discharge follow-up appointment and the importance of keeping that appointment.

It is essential for the success of your Maternal Hypertension/Preeclampsia management program that it is designed and implemented by a multi-disciplinary team comprised of the key stakeholders. Your list may include other, but minimally should include representation from obstetrics, emergency department, anesthesiology, nursing, laboratory, and pharmacy. Once your final documents are developed, do not forget to take them to medical staff committees such as Pharmacy and Therapeutics, Department of Emergency Medicine and OB-GYN along with your Patient Care Committees. These approvals are necessary and will help to create awareness within your organization.

Should you have any questions or require any additional information, do not hesitate to contact us at

1. Centers for Disease Control and Prevention. Reproductive Health, Pregnancy Mortality Surveillance System webpage. Page last reviewed: June 4, 2019. Accessed Aug. 20, 2019.
2. The Joint Commission R³ Report: Requirements, Rationale, Reference: Issue 24, August 21, 2019.

Was this helpful?

We appreciate your feedback regarding whether you found this article helpful or not.

Did you find this information helpful?

Leave a Comment

Your email address will not be published. Required fields are marked *

Shopping Cart