Policies and Procedures

A key step in establishing an MMRC is clearly documenting the policies and procedures the committee will follow. Key topics to cover in such a document include:

  • Mission, vision, scope, and goals of the committee
  • Team member roles, terms (if applicable), and guidelines
  • Authority and immunity
  • Funding
  • Maintaining confidentiality
  • Methods of case identification and selection
  • Methods for abstraction and development of a case narrative
  • Communication with committee members, including case dissemination prior to or during the meeting
  • Rules or processes governing committee proceedings and review, including facilitation and reaching consensus
  • Processes for data entry and management

The policies and procedures document should ensure that all committee members have a shared understanding of, and commitment to the purpose of the MMRC. It also documents the methods and processes that should be uniformly applied to each case review and committee meeting.


MMRIA Committee Facilitation Guide

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This guide is intended to share best practices that will help maternal mortality review committees (MMRCs) establish processes for case review. The guide is structured in the general order of steps a committee might take in conducting an actual review committee meeting. Your committee may choose to do things differently depending on your resources, committee makeup, and scope. Consider this document a tool to help you establish a strong foundation for committee facilitation from which to develop and build upon your own skills and experience.

MMRC Policies & Procedures

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A template based on policies and procedures for the Maternal Mortality Review program in Colorado.