1. TipQC—Tennessee initiative for perinatal quality Care

5. Mission
Tennessee Initiative for Perinatal Quality Care (TIPQC) seeks to improve health outcomes for mothers and infants in Tennessee by engaging key stakeholders in a perinatal quality collaborative that will identify opportunities to optimize birth outcomes and implement data- driven provider- and community-based performance improvement initiatives.

7. Goals of Tipqc Establish a statewide perinatal database
Foster state-wide quality improvement initiatives to reduce mortality and morbidity associated with premature birth and low birth weight
Promote system changes by provider organizations to increase use of evidence based clinical practices for obstetric and NICU patients

11. Maternal arm Reduction of elective deliveries before 39 weeks
Breastfeeding Promotion—delivery and post partum
Obstetric hemorrhage

12. Infant Arm NICU temperature project Golden Hour Central line infection
Human milk for NICU
Antenatal steroids
Neonatal abstinence syndrome project
Hospital acquired infection
NICU nutrition and growth

13. Why Invest Time and money??
Improves health of mothers and infants
Saves healthcare dollars
Gives hospitals tools to standardize important measures
Idea sharing and collaboration
It is the right thing to do

14. Breastfeeding and neonatal mortality
Chen and Rogan 2004
Breastfeeding showed reduction of mortality for infants 28 days-1 year
Longer breastfeeding had lower risk
Ware in 2016 is involved in a study which is confirming this data.
Chen A, Rogan W. Breastfeeding and the Risk of Postnatal Death in the United States. Pediatrics :5.

15. Breastfeeding and neonatal mortality
Promoting breastfeeding has the potential to save 720 neonatal deaths in the US each year

16. Breastfeeding and Neonatal mortality
Cochrane Review of 11 papers
Early initiation of breastfeeding reduced risk
Initiating breastfeeding after first hour doubled risk of mortality
Exclusively breastfed neonates had lower risk of mortality than partially breastfed neonates
Khan, J. Timing of Breastfeeding Initiation and Exclusivity of Breastfeeding During the First Month of Life: Effects on Neonatal Mortality and Morbidity--A Systematic Review and Meta-analysis. Maternal and Child Health Journal. March 2015, 19:3,

17. Breastfeeding and Neonatal mortality
Pneumonia is the leading cause of child mortality in children <5.
Optimal breastfeeding had greatest reduction of risk.
Lamberti L. Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health :3.

18. Breastfeeding promotion Project—TipQC 2009
2009 the obstetrical community voted to develop a project to promote breastfeeding Joint commission perinatal core measure 05—exclusive breastmilk feeding at discharge as the project outcome measure—goal to increase by 10% Project in 3 parts: antenatal, hospital, and postnatal

19. Quality Improvement Why do we care? How do we improve?
Attitude that says we have room for improvement
How do we improve?
By being perpetually curious and looking for the next step not the whole answer
Small behavior changes can have ripple effects

21. UT/St. Francis
A primary care residency clinic that provides full- spectrum care for patients—this includes OB and pediatric care
Faculty include 11 family medicine physicians, 2 OB/GYNs, 2 pharmacists and 1 therapist
24 1st-3rd year residents

22. Our multidisciplinary team--Bridgette Erasmus, MA, Katosha Muse-resident, Andrea Green lpn, Lisa Canon RN, and myself

23. Importance of Early intervention
Studies have shown 50-90% of pregnant women decide how they will feed their child either before becoming pregnant or very early in their pregnancy5
Breastfeeding intentions appear to be significant predictors of breastfeeding initiation and duration6

25. Comparing rates
Source: CDC Breastfeeding Report Cart—United States, 2009.
St. Francis patient info from deliveries June 1, 2009-Nov 30, 2009
three month info actually 2 month info.

26. Demographics for Breastfeeding Behaviors5
Women who breastfeed for longer durations tend to be:
Caucasian
Older
Married
Better educated
Have higher incomes

27. Demographics of St. Francis Patients

28. Demographics of St. Francis Patients

29. Demographics of St. Francis Patients

30. Demographics of St. Francis Patients
INSURANCE
Tenncare
88.1%
BlueCross 5%
Cigna 4%
Other 3%

31. Baseline Rates

33. AIM
The aim of this project is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting breastfeeding at prenatal care visits. While barriers to successful breastfeeding exist in multiple settings, we will focus on high reliability (>90%) implementation of processes that promote breastfeeding in the prenatal clinic. Thus, we seek to increase the fraction of infants who are fed breast milk at the maternal post-partum visit by 50% by March 2012.
Caption for the following 7 slides

35. PROJECT PLAN (LAUNCHED 11.1.11)
Provide at first provider visit:
“ Breastfeeding vs. Bottle feeding” handout
Document on ACOG blue sheet
At 1 hour GTT office visit:
Patient will view a breastfeeding DVD
Provide at GBS visit:
MALCA handout
“Breastfeeding: Hints to a Good Start” handout
“Prescription for Breastfeeding” for provider to dispense / discuss
Continue to conduct six week PP visit infant feeding survey
For baseline and outcome measurement

36. FIRST TRIMESTER
SECOND TRIMESTER
THIRD TRIMESTER
Gave “Breastfeeding vs. Bottle Feeding”
Gave USDHHS book
Date­­­­______
Signature____________________________
Viewed Breastfeeding DVD at GTT visit
Gave “101 Reasons to Breastfeed”
Date______
Signature_______________________
Gave MALCA Trifold
Gave “Breastfeeding Hints”
Date_______
Signature_________________________
Physical Exam of Breasts
Discuss benefits of breastfeeding
Discuss exposure to breastfeeding and barriers
Barriers:____________________________
___________________________________
Breastfeeding Plans:
Breast/Formula/ Undecided
Duration: _______Months
Date___________
Discuss breastfeeding plans and address barriers
Breast/Formula
Date__________
Gave ”Rx to Breastfeed”
Discuss skin to skin contact at delivery and importance of initiating breastfeeding immediately
Discuss plans for rooming in
PROVIDER SIGNATURE (AS REQUIRED)­­­ ______________________________________________________

37. UT Medical Group, Inc.
Family Medicine - St Francis
Prescription: At least six months of
Breast Milk for Baby________________
Start date: At Birth
Benefits for baby:
• Lower risk of:
• Sudden Infant Death Syndrome (SIDS),
• Being severely overweight (obese),
• Infections, asthma, diabetes, ear infections, and allergies
• Higher IQ (on average, compared to babies
who are only formula fed)
• Breast milk is easier for baby to digest than formula
• Breast milk has all the nutrients, calories, growth factors, & fluids a baby needs to be healthy
Benefits for Mom:
• Releases body hormones that promote mothering behavior
• Saves money and time
(breast milk is free and always ready and available!)
• Help lose the “baby” weight
• Help prevent postpartum depression
• Lower risk of breast and ovarian cancer
• Lower risk of osteoporosis (weak bones)
_______________________________________, MD
Flip over for more 
Prescription to breastfeed is intended for educational purposes only

40. OUTCOME MEASUREMENT Six Week PP Visit: Infant Feeding Assessment:
How is baby currently fed?
Check one:
 Breast milk only
(breastfeeding and/or pumped breast milk)
Breast milk and formula
 Formula only
Has baby been readmitted to the hospital?
Yes No

41. Project Data (as of 2/24/12)

42. Breastfeeding Promotion Outcomes
11 hospitals joined project by 2012
Increased exclusive breastfeeding at discharge from % which is a relative increase of 13.5%
In 2013 the project teams voted to continue to work to implement the 10 steps to successful breastfeeding

43. Why Invest Time and money??
Improves health of mothers and infants
Saves healthcare dollars
Gives hospitals tools to standardize important measures
Idea sharing and collaboration
It is the right thing to do