1. Birth & Beyond California: Continuous Quality Improvement Project Decision Maker Course 2009 Cycle 4 1

2. 2 Disclosures No 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

3. 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

4. Objectives After 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

5. Objectives After 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

6. 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

7. The Role of the Hospital 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 Trainers 7

8. Breastfeeding: Important for Babies Reduced Risk of Disease 8 Source: AHRQ, 2007

9. Breastfeeding: Important for Mothers Reduced Risk of Disease 9 Source: AHRQ, 2007

10. 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 10 California Department of Public Health Maternal, Child, and Adolescent Health Program

11. 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

12. California Any and Exclusive In- Hospital Breastfeeding: 1994-2007 12 Data 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

13. Percent Any/Exclusive In Hospital Breastfeeding: 2007 13 Gap

14. 2007 California’s Best Any/Exclusive Breastfeeding 14

15. California’s Lowest Scoring Hospitals 2007 15

16. Best LA Hospitals Exclusive Breastfeeding 2007 16

17. Percent Any/Exclusive In Hospital Breastfeeding: 2007 Closing the Gap 17 Closed the Gap Closing

18. Hospital X 2004- 2007 Any/Exclusive Breastfeeding 18

19. 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

20. Hospital Practices: Associated with breastfeeding duration 20 Murray, Birth, 2007

21. 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

22. 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

23. 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

24. CDC Guide to Breastfeeding Interventions Evidence Based Maternity Care Interventions Improve breastfeeding rates Shealy, CDC, 2005 24

25. Providing Breastfeeding Support: Model Hospital Policy Recommendations Model Hospital Policy Recommendations Toolkit cdph.ca.gov/Breastfeeding 25

26. 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/Breastfeeding

27. 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 Know10% Formula not given 9% Doctor prescribed formula 4% 27 SLAHP Breastfeeding Peer Counselor Support Project Baseline Report 2004

28. Did mothers get what they wanted? 28 SLAHP Breastfeeding Peer Counselor Support Project Baseline Report 2004

29. 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

30. Birth & Beyond California Participating Hospitals California Hospital Medical Center Good Samaritan Hospital Henry Mayo Medical Center Huntington Memorial Hospital Long 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 30

31. Restoring the Original Paradigm The original “model or pattern” Miriam-Webster Dictionary DVD by Nils Bergman, MD 31

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

33. Our Goal To help your staff get better results with less time & effort 33

34. 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

35. 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. 36

37. 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

38. 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 California 38

39. Team Required Members 1.Physician 2.Administration 3.Nursing 4.Quality Improvement 5.Nutrition 6.Lactation Optional Members –Pharmacy –OT –OB/Peds Clinics –Others? 39

40. Role of the BBC Network Who? –MCH Directors, QI Team Members, Nurse Managers, Trainers What? –Monthly interactive discussion Why? –Support –Information sharing –Celebrating successes –Keep staff motivated! 40

41. 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 41

42. 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

43. 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

44. Action Plan Immediate Action Steps? 44

45. Thank You! 45 Please complete the Post Test & Evaluation form