Birth & Beyond California:Continuous

Quality Improvement Project

Decision Maker Course

2009

Cycle 41

2

DisclosuresNo one involved in this activity has any relevant financial relationships with commercial interests.

• Julie Barker, CHES, MPH• Carolyn Buenaflor, MPH• Cynthia Fahey, MSN, RN• Suzanne Haydu, MPH, RD• Emily Lindsey, IBCLC• Sheila Marton, RN, IBCLC• Lorraine Miles, RN, FACCE,

IBCLC• Jeanette Panchula, RN,

PHN, IBCLC

• Denise Parker, IBCLC• Karen Peters, MBA, RD,

LCCE, IBCLC• Karen Ramstrom, DO, MSPH• Sadie Sacks, MSN, RN• Carina Saraiva, MPH• Leona Shields, PHN, MN, NP• Ellen Steinberg, RN, LCCE,

IBCLC• Louise Arce Tellalian, RN,

LCCE, FACCE, CLC

Acknowledgements

• Funded from Title V Block Grant, California Department of Public Health, Maternal, Child, Adolescent Division

• In collaboration with – Regional Perinatal Programs of California– Breastfeeding Task Force of Greater LA

• Adapted from Perinatal Services Network, Loma Linda University

3

ObjectivesAfter attending this event, the participant will be able to:

• Describe three model hospital breastfeeding practices which improve breastfeeding rates

• Define the “gap” between any and exclusive breastfeeding rates

• List two hospital practices that discourage exclusive breastfeeding

4

ObjectivesAfter attending this event, the participant will be able to:

• Identify at least one hospital policy the QI Team will address to encourage breastfeeding

• Identify how California Department of Public Health collects exclusive breastfeeding data

• Describe a benefit of a Breastfeeding QI team and process in a hospital

5

Workshop Overview

• Presentation:– Literature review– Breastfeeding rates– Model Breastfeeding Policies– Birth & Beyond Project

• Action Plan Development– Identify the ‘next steps’ to improve

breastfeeding rates in this hospital

6

The Role of theHospital Administrator

• Become familiar with Birth & Beyond CA (BBC)

• Assign key decision makers to participate in the monthly BBC Regional QI Network

• Identify staff that will be part of your hospital Breastfeeding Interdisciplinary QI Team– Include the Team as part of QI or other already existing

structures – Support the Team in decisions taken to improve

breastfeeding rates

• Identify staff to become your hospital Trainers7

Breastfeeding: Important for BabiesReduced Risk of Disease

8

Source: AHRQ, 2007

Breastfeeding: Important for MothersReduced Risk of Disease

9

Source: AHRQ, 2007

In-Hospital Breastfeeding Data Source:Newborn Screening Program

• Administered by the Genetic Disease Screening Program (GDSP)

• Primary purpose is to collect infant blood samples to screen for genetic diseases

• Staff complete the forms following the instructions provided by GDSP

• Summary data is sent to the Epidemiology staff of the Maternal, Child and Adolescent Health Program and made available on-line

10California Department of Public HealthMaternal, Child, and Adolescent Health Program

Breastfeeding Categories

• “ANY BREASTFEEDING” – Includes infants fed only human milk and infants fed a

combination of human milk and formula

• “EXCLUSIVE BREASTFEEDING” – Infants fed only human milk– Recommended by American Academy of Pediatrics, American

College of Obstetricians and Gynecologists, Academy of Family Physicians, American Dietetic Association

– In-hospital exclusive breastfeeding is associated with breastfeeding duration after discharge

11

California Any and Exclusive In-Hospital Breastfeeding: 1994-2007

43%43%44% 44% 43% 44% 44% 44% 43% 43% 43% 42% 42% 42%

87%87%86%86%86%85%84%84%83%82%80%79%77%77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Exclusive Breastfeeding Any Breastfeeding

12Data Source: California Department of Public Health, Genetic Disease Screening Program, Newborn Screening Database 1994-2007 Prepared by: California Department of Public Health, Maternal, Child and Adolescent Health Program Note: Includes cases with feeding marked ‘BRO’ (Breast Only), ‘FOO’ (Formula Only), or ‘BRF’ (Breast & Formula)

The “GAP” is Growing

Percent Any/Exclusive In Hospital Breastfeeding: 2007

81%86%

83%87%

43%

24%30%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

California Average LA County Average Orange County Average Central Valley Average

Any BF Exclusive BF

13

Gap

2007 California’s BestAny/Exclusive Breastfeeding

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EL CAMIN

O

HAYWARD K

AISER *

MONTEREY P

ENi COMMUNIT

Y*

SCRIPPS M

EMORIAL L

A JOLL

A

FRENCH HOSPIT

AL

SUTTER MATERNIT

Y & S

URGERY

ALTA B

ATES COMMUNIT

Y

STANFORD/LUCILE

S. P

ACKARD

SCRIPPS M

EMORIAL E

NCINIT

AS*

MERCY MED C

TR REDDIN

G

FEATHER RIV

ER HOSPITA

L

SAN FRANCIS

CO GENERAL*

MARSHALL HOSPIT

AL

SAINT A

GNES MEDIC

AL CENTER

RIDGECREST R

EGIONAL H

OSPITAL

Any BF Exclusive BF

14

California’s Lowest Scoring Hospitals 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pacific

Allia

nce

Pacific

a Hos

p Vall

ey

Bellflo

wer

Costal C

omm

unities

Anaheim

Gen

eral

LA Met

ro

Weste

rn M

ed C

tr Anah

eim

Garden

Gro

ve

Valley

Pre

sbyter

ian

Bever

ly

St Fra

ncis

Montclair

Garfie

ldKer

n

Califo

rnia

Any BF Exclusive BF

15

Best LA HospitalsExclusive Breastfeeding 2007

89%92%94%92%91%

95%

69%66% 61%

55% 53% 51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St Johns Santa Monica Holy Cross* UCLA Cedars San Dimas

Any BF Exclusive BF

16

Percent Any/Exclusive In Hospital Breastfeeding: 2007

Closing the Gap

17

Closed the GapClosed the Gap

Closing

Hospital X2004- 2007

Any/Exclusive Breastfeeding

90%89%91%89%

54.3%50.0%

52.2%47.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2004 2005 2006 2007

Any BF Exclusive BF

18

Hospital Policy is Key

• Hospitals with written policy have better breastfeeding outcomes at 2 weeks

• Administrative prioritization of breastfeeding support drives the hospital practices that lead to improved breastfeeding

• Monitor improvements in breastfeeding support over time

19

Rosenberg, Breastfeeding Medicine, 2008

Hospital Practices:

Associated with breastfeeding duration

0 25 50 75 100

Baby breastfed in 1st hour after birth

Baby fed only breastmilk in hospital

Baby stayed in same room with mother

Baby did not use pacifier in hospital

Hospital gave mother phone number to call forbreastfeeding help

Percent

No

Yes

20Murray ,Murray , Birth, Birth, 20072007

Hospital Policies: Increased number of “Baby-Friendly” Hospital

practices in place decreases risk of breastfeeding cessation

DiGirolamo, Pediatrics, 2008

21

Steps measured: Early bf initiation Exclusive breastfeeding

Rooming-in On-demand feedings

No pacifiers Information provided

Breastfeeding Duration

• Breastfeeding at 6 months was associated with – Exclusive breastfeeding in hospital– Not receiving a gift pack with formula at

hospital discharge

22

Dabritz, J Hum Lact, 2008

Hospital Policies: Affect all ethnicities & income levels • Breastfeeding rates in US Baby-Friendly

Hospitals exceed state and regional rates across all ethnicities and income levels

• Breastfeeding rates are high in these hospitals even among populations who do not traditionally breastfeed

23

Merewood, Pediatrics, 2005

CDC Guide to Breastfeeding Interventions

• Evidence Based Maternity Care Interventions

• Improve breastfeeding rates

Shealy, CDC, 2005

24

• Providing Breastfeeding Support: Model Hospital Policy Recommendations

• Model Hospital Policy Recommendations Toolkit

cdph.ca.gov/Breastfeeding

25

California Model Hospital Policy Recommendations Toolkit

• Basic information and guidance to revise policies that affect the breastfeeding mother

• Rationale and references are included as education for those unfamiliar with current breastfeeding recommendations

26

cdph.ca.gov/Breastfeedingcdph.ca.gov/Breastfeeding

Why Formula Was Used

• Provided without the mother asking for it or the doctor prescribing it.64%

• Formula was requested by the mother 13%

• Don’t Know 10%

• Formula not given 9%

• Doctor prescribed formula 4%

27

SLAHP Breastfeeding Peer Counselor Support Project SLAHP Breastfeeding Peer Counselor Support Project Baseline Report 2004Baseline Report 2004

Did mothers get what they wanted?

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Plan Actual - 2 wks PP Actual - 3 months PP

Exclusive BF Combo Exclusive Formula

28SLAHP Breastfeeding Peer Counselor Support Project SLAHP Breastfeeding Peer Counselor Support Project Baseline Report 2004Baseline Report 2004

29

Birth & Beyond California

• Quality Improvement– Support for your QI team– Policy revision technical assistance– Technical assistance and tools for data

collection and analysis tailored to your hospital• BBC Regional QI Network meetings

– Monthly• Training

– 2 hour Decision Maker – 16 hour Learner Workshop– 16 hour Train the Trainer

Birth & Beyond CaliforniaParticipating Hospitals

California Hospital Medical Center

Good Samaritan HospitalHenry Mayo Medical

CenterHuntington Memorial

HospitalLong Beach Memorial:

Miller Children’s Hospital

Northridge Hospital Medical Center

Olive View – UCLA Medical Center

Pomona Valley Hospital Medical Center

Providence Holy Cross Medical Center

Providence St. Joseph Medical Center

Providence Tarzana Medical Center

St. Francis Hospital Lynwood

Torrance Memorial Hospital

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Restoring the Original Paradigm

The original “model or pattern”Miriam-Webster Dictionary

DVD by Nils Bergman, MD

31

The physiologic norm is easier

• Skin to skin triggers – Infant competence – Appropriate maternal responses

• Exclusive breastfeeding in the early days promotes a cascade of breastfeeding successes

• Mother/baby togetherness in the early days enhances parental competence

32Moore, Cochrane Review, 2007Chiu, Breastfeeding Medicine, 2008

Our Goal

To help your staff

get better results with

less time & effort

33

Benefits of Breastfeeding Quality Improvement

• Mother & Baby– Increased attachment & bonding– Optimal infant nutrition & health– Patient satisfaction

• Hospital– Joint Commission – Continuous Quality Improvement– Increased staff competence and self-efficacy– Supports marketing– Increased teamwork– Worksite Lactation Support: Reduced absenteeism

• Others?34

Costs of Breastfeeding Quality Improvement

• Staff Education– Nurses’ time for training– Trainers’ time– Back up staff during trainings– Classroom supplies

• Data collection

• Facility Improvements

• Others?

35

36

Breastfeeding Makes Good Business Sense

• Lower Absenteeism Rates

• Lower Healthcare Costs

• Lower Turnover Rates

• Higher Employee Productivity and Morale

• Higher Employer Loyalty

• Recognition as a “Family Friendly” Business

37

Role of Your Breastfeeding Interdisciplinary QI Team

• Work with key staff to interpret results of the self-appraisal tool

• Develop breastfeeding policies• Facilitate training & systems change • Monitor policy adherence & evaluation

data• Technical assistance available from the

Regional Perinatal Programs of California38

Team

• Required Members1. Physician

2. Administration

3. Nursing

4. Quality Improvement

5. Nutrition

6. Lactation

• Optional Members– Pharmacy– OT– OB/Peds

Clinics– Others?

39

Role of theBBC Network

• Who?– MCH Directors, QI Team Members, Nurse Managers,

Trainers

• What?– Monthly interactive discussion

• Why?– Support – Information sharing – Celebrating successes – Keep staff motivated!

40

Role of Your BBC Trainers

• Attend the Learner Workshop – Observe Master Trainers presenting the model 16

hour BBC Course– Provide onsite coordination – Participate with colleagues in the learner centered

activities

• Attend the 16 hour Train-the-Trainer Workshop– Improve knowledge of teaching adults– Practice using the BBC Curriculum & tools– Plan for sustainability of training activities

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Training Sustainability

Recommendations for Maximum Impact • Budget for and plan mandatory training for all

mother baby staff within the first year– 16 hours didactic– 3 hours clinical

• Plan on repeating the 16 hour course– Annually, biannually, quarterly– Depending on your new hire training requirements

42

Medical Staff Training Ideas

– Identify physician champions and CME programs

– Committee Meetings– Grand Rounds– Self Study Modules– Hospital staff providing “lunch & learn”

sessions to medical office staff

43

Action Plan

• Immediate Action Steps?

44

Thank You!

45

Please complete the Post Test &

Evaluation form