MAWS Quality Management Program: Incident & Peer Review
Regular engagement in reflective self and peer evaluation is a public demonstration of the midwifery profession's commitment to providing safe, responsible, family-centered care. The Quality Management Program (QMP) is state sanctioned and legally protected by WAC 246-834-360. It was established by MAWS in 2003 with the aim of furthering the autonomy of the midwifery profession and improving practice and outcomes, and is administered by the QMP committee. The protected space of Peer Review and Incident Review enables midwives to freely discuss clinical cases with their peers, safe from subpoena or legal inquiry.
The Quality Management Program (QMP) exists to:
The two branches of the QMP program provide mechanisms for quality improvement:
a) Peer Review
MAWS members are required to complete Peer Review of 5 charts every 2 years, in alignment with Washington State’s new Peer Review requirement for licensure. For Peer Review to meet the requirements and remain protected, there must be at least four licensed midwives, all of whom are CURRENT MAWS members. You can check your member status via your profile at https://maws.wildapricot.org/.
Student midwives are now allowed to participate in Peer Review if they are:
Getting Peer Review certificates is now entirely self-service, paperless, and immediate. We recognize that while it has always been the responsibility of each individual midwife to make peer review meaningful and educational, it is also each midwife's responsibility to guarantee confidentiality, a quorum of 4 professional midwives, and compliance with DOH guidelines that allow for legally protected peer review.
With the new process, after conducting a peer review, each participant will fill out an online form answering the necessary questions and attest to confidentiality and active professional MAWS membership. Upon completion, your certificate will be emailed to you within minutes.
MAWS Peer Review Self-Service Certificate Link
Troubleshooting: If you don't receive your certificate within a few minutes of completing the form, try the following:
b) Incident Review is organized by the QMP committee and is conducted by a specially convened panel whenever an outcome occurs which meets “Sentinel Event” criteria.
As MAWS members, we all have a shared responsibility to:
Click here for Incident Review Instructions.
All documents related to Incident Review docs should continue to be faxed through the secure fax number: 1-206-691-8203. The QMP Committee will no longer accept paper copies of Incident Review documents due to PHI HIPAA risks.
Please contact us if you have questions:
Incident/Peer Review and general QMP correspondence: QMP@washingtonmidwives.org
OR FAX to the QMP at: 1-206-691-8203
The Quality Management Program (QMP) exists to:
- Help midwives improve their practice
- Help improve future outcomes
- Create a safe forum for discussion of clinical cases
- Generate ideas directly from the membership for continuing education
The two branches of the QMP program provide mechanisms for quality improvement:
a) Peer Review
MAWS members are required to complete Peer Review of 5 charts every 2 years, in alignment with Washington State’s new Peer Review requirement for licensure. For Peer Review to meet the requirements and remain protected, there must be at least four licensed midwives, all of whom are CURRENT MAWS members. You can check your member status via your profile at https://maws.wildapricot.org/.
Student midwives are now allowed to participate in Peer Review if they are:
- A MAWS member
- Accompanied by their precepting midwife
- Approved by all midwives who will be part of the Peer Review
Getting Peer Review certificates is now entirely self-service, paperless, and immediate. We recognize that while it has always been the responsibility of each individual midwife to make peer review meaningful and educational, it is also each midwife's responsibility to guarantee confidentiality, a quorum of 4 professional midwives, and compliance with DOH guidelines that allow for legally protected peer review.
With the new process, after conducting a peer review, each participant will fill out an online form answering the necessary questions and attest to confidentiality and active professional MAWS membership. Upon completion, your certificate will be emailed to you within minutes.
MAWS Peer Review Self-Service Certificate Link
Troubleshooting: If you don't receive your certificate within a few minutes of completing the form, try the following:
- Refresh your inbox and check your spam folder
- Ensure that you entered the correct email address with no typos
- Ensure that you answered all questions completely, including entering an "N/A" to any that don't apply.
- If all else fails, email MAWS at info@washingtonmidwives.org
- You can complete the form as many times as you need to.
b) Incident Review is organized by the QMP committee and is conducted by a specially convened panel whenever an outcome occurs which meets “Sentinel Event” criteria.
As MAWS members, we all have a shared responsibility to:
- Agree to participate as a panelist on an Incident Review Panel when called upon to do so
- Maintain strict confidentiality whenever participating in Peer Review or on an Incident Review Panel
- File an Online Incident Self-Report to the QMP within 14 days if any of the following “Sentinel Events” occur. If you are uncertain about whether a serious event meets criteria for an Incident Review, please submit one.
- Birth-giver/Maternal mortality or significant morbidity including but not limited to uterine rupture, ICU admission, seizure, or shock/prolonged vital instability unresponsive to treatment, or administration of magnesium sulfate or epinephrine.
- Perinatal mortality or significant morbidity including but not limited to:
- Respiratory distress requiring prolonged ventilation
- Severe hyperbilirubinemia
- Hypoglycemia unresponsive to feeding
- Severe IUGR
- Birth injury
- NICU or Special Care Nursery admission within 72 hours of birth, except for observation-only or for congenital anomalies
- Failure to thrive <10% weight loss not responding to feeding plan
- Transfer to another medical facility for procedures unavailable at referring hospital
Click here for Incident Review Instructions.
All documents related to Incident Review docs should continue to be faxed through the secure fax number: 1-206-691-8203. The QMP Committee will no longer accept paper copies of Incident Review documents due to PHI HIPAA risks.
Please contact us if you have questions:
Incident/Peer Review and general QMP correspondence: QMP@washingtonmidwives.org
OR FAX to the QMP at: 1-206-691-8203
How to File a Complaint
MAWS is aware that some healthcare providers, consumers, or family members may have concerns about the care provided by a Licensed Midwife who is also a MAWS member. Any patient, client, family member, healthcare provider, allied birth professional, or facility may file a complaint against one of our midwives to the Quality Management Program (QMP). Click here to download the Complaint Form. Please be aware that a review of the event in question requires contacting the midwife and reviewing the chart notes, and therefore we cannot maintain client anonymity. The QMP upholds the highest standards of confidentiality and safety. Because of this very commitment to confidentiality, complainants will not receive any information about the results of such a review.
Once a complaint is received, the QMP Committee reviews the information and begins a review if the case meets criteria for investigation. Review panels are convened and the findings are reported back to the MAWS QMP committee. If any laws have been broken we are obligated to notify the Department of Health.
As a statewide midwifery organization, we appreciate your feedback in order to identify practice trends or any gaps in education. We organize annual Continuing Education Conferences for our members based partly on incident and peer review data. MAWS members are committed to the continuous improvement of maternity care services in Washington State.
Once a complaint is received, the QMP Committee reviews the information and begins a review if the case meets criteria for investigation. Review panels are convened and the findings are reported back to the MAWS QMP committee. If any laws have been broken we are obligated to notify the Department of Health.
As a statewide midwifery organization, we appreciate your feedback in order to identify practice trends or any gaps in education. We organize annual Continuing Education Conferences for our members based partly on incident and peer review data. MAWS members are committed to the continuous improvement of maternity care services in Washington State.