Section 640.APPENDIX G   Sample Letter of Agreement

_________________ (name of Administrative Perinatal Center) is recognized and designated by the Illinois Department of Public Health as a Level III Administrative Perinatal Center providing obstetrical and neonatal care.  In order to serve as a Non-Birthing Hospital, Level I, II, II with Extended Neonatal Capabilities or III, affiliated with an Administrative Perinatal Center designated by the Illinois Department of Public Health, __________________(name and address of hospital) agrees to affiliate with the above Administrative Perinatal Center.

This agreement is consistent with the Illinois Department of Public Health, Regionalized Perinatal Health Care Code (77 Ill. Adm. Code 640).

Components for Letter of Agreement

I.          Introductory Remarks:  The Administrative Perinatal Center may list items of organization of the Center.

II.        Administrative Perinatal Center Obligations

A.        A 24-hour obstetrical and neonatal "hot-line" for immediate consultation, referral or transport of perinatal patients is available.

B.        The Administrative Perinatal Center shall accept all medically eligible obstetrical/neonatal patients.

C.        If the above named Administrative Perinatal Center is unable to accept a referred maternal or neonatal patient because of bed unavailability, that Center shall assist in arranging for admission of the patient to another hospital capable of providing the appropriate level of care.

D.        Transportation of neonatal patients remains the responsibility of the Administrative Perinatal Center.  Decisions regarding transport and mode of transport will be made by the Administrative Perinatal Center neonatologist in collaboration with the referring health care provider.

E.        Transportation of the obstetrical patient remains the responsibility of the (Level I, Level II, Level II with Extended Neonatal Capabilities or Level III hospital). Decisions regarding transport, transfer and mode of transport or transfer shall be made by the Administrative Perinatal Center maternal-fetal medicine physician in collaboration with the referring health care provider.

F.        The maternal-fetal medicine physician of the Administrative Perinatal Center, in collaboration with the referring health care provider, shall decide whether to have an obstetrical patient stabilized before transfer, kept in the affiliated unit or transferred immediately.  The best possible alternatives and the staff needed for transport shall be determined.

G.        The Administrative Perinatal Center shall distribute written protocols for the mechanism of referral/transfer/transport to the affiliated hospital physician, administration and nursing service. Protocols are to include a mechanism for data recording of the time, date and circumstances of transfer so that this information can be part of the morbidity and mortality reviews.  (See Appendix A.)

H.        The Administrative Perinatal Center shall send a written summary of patient management and outcome to the referring health care provider of record and to the hospital.

I.         The Administrative Perinatal Center shall conduct quarterly mortality and morbidity conferences at __________________________ Hospital.

1.         The Administrative Perinatal Center's Perinatal Network Administrator, maternal-fetal medicine physician, neonatologistand/or obstetrical and neonatal nurse educators shall conduct the conference.

2.         ______________________ Hospital shall prepare written summaries of cases and statistics for discussion, to be available to the Administrative Perinatal Center at least one week prior to the conference.

3.         The Regional Quality Council of each Regional Perinatal Network shall determine the content of the review.  The review shall include, but not be limited to, stillbirths, neonatal deaths, maternal and/or neonatal transports.

J.         The Administrative Perinatal Center shall transfer patients back to the referring hospital when medically feasible, in accordance with physician to physician consultation.

K.        The Administrative Perinatal Center shall develop and offer Perinatal Outreach Education programs at a reasonable cost to include the following:

1.         On-site consultation by Administrative Perinatal Center physicians and nurse educators as needed.

2.         Periodic obstetrical and neonatal needs assessment of ______________ Hospital.

3.         Provide __________________ Hospital with protocols for patient management.

4.         Develop Continuing Medical Education programs for obstetricians, pediatricians and family practitioners either at __________________ Hospital or at the Administrative Perinatal Center site.

5.         Mini-Fellowships at the Administrative Perinatal Center for __________________ Hospital physicians and nurses.

6.         Programs based on needs assessment by outreach nurse educators at __________________ Hospital for obstetrical and neonatal nursing staff.

L.        The Administrative Perinatal Center shall establish, maintain and coordinate the educational programs offered for all Non-Birthing Centers, Level I, Level II, Level II with Extended Neonatal Capabilities, and Level III hospitals that it serves.

M.       The Administrative Perinatal Center shall develop a Regional Quality Council, including, but not limited to, representatives of each hospital in the Regional Perinatal Network.  This group shall meet at least quarterly to plan management strategies, evaluate morbidity and mortality reviews, evaluate the effectiveness of current programs and services and set future goals.  The Regional Quality Council shall determine the data collection system to be used by the Regional Perinatal Network.

III.       __________________ Hospital Obligations

A.        __________________ Hospital shall utilize the "hot-line" established by the Administrative Perinatal Center for consultation, referral and transport.

B.        __________________ Hospital shall transfer to __________________ Administrative Perinatal Center obstetrical and neonatal patients who require the services of the Administrative Perinatal Center, including, but not limited to, patients outlined in the Regionalized Perinatal Health Care Code.

C.        __________________ Hospital (level of care) shall usually care for the following maternal and neonatal patients. 

D.        __________________ Hospital shall develop an ongoing in-house continuing educational program for the obstetrical and neonatal medical staff and other disciplines as needed.

E.        __________________ Hospital shall participate in continuing educational programs for both nurses and physicians developed by the __________________ Administrative Perinatal Center.  Cost to be shared.

F.        __________________ Hospital shall designate representatives to serve on the __________________ Regional Quality Council.

G.        __________________ Hospital shall establish a Perinatal Development Committee composed of medical and nursing representatives from both neonatal and obstetrical areas, administration and any other individuals deemed appropriate.

H.        __________________ Hospital shall maintain and share such statistics as the __________________ Regional Quality Council may deem appropriate.

I.         __________________ Hospital shall develop or to utilize programs at __________________ Administrative Perinatal Center for follow-up of neonates with handicapping conditions.

IV.       Joint Responsibilities

A.        This agreement will be valid for three years, at which time it may be renewed or re-negotiated.

B.        If either __________________ Hospital or the __________________ Administrative Perinatal Center wishes to change an individualized portion of this agreement, either may initiate the discussion.  If a change in the agreement is reached, the change must be reviewed by the Department.  If the __________________ Hospital wishes to make a change and __________________ Administrative Perinatal Center is not in agreement, __________________ Hospital can request a hearing by the Department.

C.        If any of the institutions wants to terminate the agreement, written notification shall be given to the Department and other participating institutions six months in advance.

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