Melanie Conant BSN RN Nurse Educator (LD, NSY, PP) Imelda Marrero BSN RN IT Clinical Informatics Analyst (CPN, Vocera, ANSOS)

Medical Center Hospital Women and Infant wing built in 2012 Odessa, Texas

Medical Center Hospital 402 bed level II trauma Center Center For Women and Infant – L&D, Postpartum, Nursery, NICU Close to 2,000 deliveries a year All Private Rooms – 12 LDRs, 30 Postpartum, 30 NICU Used CPN for over 15 years, currently at version

“The content of this presentation represents the views of the author and presenter. GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric Company.” “The faculty and planning committee have declared no conflict of interest.” Disclosures:

Objectives: At the end of the presentation, the participants will: Describe the requirements for compliance of Exclusive Breastmilk Feeding Core Measure. Recognize what charting elements are required to pass PC05 core measure. Explain how to build charting elements required to comply with requirements of the PC05 Core Measure. Identify how the Data Reporting Module supports data collection for core measure reporting. Criteria for successful completion include attending the entire session and turning in an evaluation form.

Perinatal Core Abstractions Who’s doing it? Who are we reporting to?

How is breastmilk defined? The Joint Commission defines exclusive breast milk feeding as “a newborn receiving only breast milk and no other liquids except for drops or syrups consisting of vitamins, minerals, or medicines”

What are the Allowable Values For PC05? AV1- There is documentation of a reason for not exclusively feeding breast milk during the infants stay due to a maternal medical condition with which breastmilk should be avoided. AV2- There is documentation that the newborn’s mother chose to not exclusively breastfeed breast milk upon admission AV3 (FAIL) There is no documentation in the record for not exclusively breastfeeding, including UTD.

Allowable values for not exclusively breast feeding Maternal Conditions Maternal Initial Feeding Plan Undetermined

Breastfeeding Discussion Requirement The initial feeding plan discussion prior to first feeding must appear in newborn’s record IBCLC or CLC/physician must validate information given RN documentation requires additional validation (more than just a check box) Mother’s record cannot be used if linked via EHRs (Mother-Baby Link) Must read formula Discussion prior to admission is acceptable as long as it appears in newborn’s record

What if they change their minds? If the mother choses to breast/formula feed on admission as a mother’s choice, a lactation discussion must be performed before the initial feeding for this measure to count.

Where can abstractors find this information? Discharge Summary Feeding flow sheets Individual treatment plans Intake and output sheets Nursing notes Physician progress notes

Workflow Mother states Breast Mother states Breast/Formula Mother states Formula The nurse admitting the newborn will initiate a lactation discussion Reason must be entered

All lactation discussions must be verified! If there is no documentation in the chart that a lactation discussion or verification took place, AV2 cannot be used. NOTE!!

Challenges with Core Measure Compliance Charting Challenges finding needed information after charting was done Nurse resistance to change Evolving core measure Understanding the core measure

THE BUILD

Definition and description of the core measure was confusing. Build and rebuild forms and workflows dependent on interpretation of core measure. Challenges with the Build

Changed verbiage from Breast, Bottle, Both, and Undecided. Perinatal View/LD View

All other documentation on lactation needs to be done on the baby’s chart.

Nurses were not going to the flowsheet to document on necessary lactation items. Nurses were not completing intake and output – complexity with creating intake and output elements. Other Issues Identified Fix: Created a new Intake and Output form that was more user friendly and incorporated charting elements for lactation.

Replaced Intake and Output Form

Physician Discharge Summary Review chart provides information on feedings during hospital stay. Physician also has to complete documentation if infant is not exclusively breastfeeding.

Newborn Flowsheet Addendum Contains lactation documentation from floor RN, lactation consultant and Pediatrician in one chart. Makes it easier for doing manual chart audits

DRM Report

Not able to automate report through DRM.

References The Joint Commission. (n.d.) Retrieved from Core Measure Sets: The Joint Commission. (2013, November). Core Measure Sets. Joint Commission Perspective, 33(11), Retrieved from the Joint Commission: CPN Clinical Configuration Manual CPN Options Configuration Manual