The Gift Designation Expedited Application for Baby-Friendly™
Facilities Already Designated by Baby-Friendly USA
Birthing Facility Information and Administrative Leader Sign-Off
Name of Facility: Click here to enter text.
Main Contact Person Name and Title: Click here to enter text.
Complete Mailing Address of Birthing Facility (include city and zip code): Click here to enter text.
☐Facility has been designated as Baby-Friendly by Baby-Friendly USA. (Attach a copy of the designation award with this signed application.)
☐I hereby consent to submission for consideration by the Louisiana Department of Health and Hospitals-Office of Public Health-Bureau of Family
Health appointed Application Review Committee.
☐I agree to have the designation decision listed on The Gift program’s website.
Click here to enter text.
Print Name of CEO or COO
_______________________________
Signature, Date
Please continue to pages 2-4 of this application to complete the Birthing Facility Data Sheet.
Rev. 4/8/2014
The Gift Designation
Expedited Application
Page 1
Expedited Application Birthing Facility Data Sheet
Facility Type:
1. Does the facility provide prenatal care or prenatal services? ☐ No
2. Does the facility have a high risk antenatal unit?
☐ No
3. Does the facility have a Neonatal Intensive Care Unit (NICU)? ☐ No
☐ Yes
☐ Yes
☐ Yes
If yes, what level(s) of care is the NICU? Click here to enter text.
Number of live births in most recent complete calendar year of data:
Indicate the start date Click here to enter a date. and end date Click here to enter a date. of the data set.
Total Number of Live Births: Click here to enter text.
Lactation Consultant Staffing
1. Current number of full time equivalents (FTEs) dedicated to lactation patient care (If less than 1 FTE, record as decimal. For example, 40 hours per week=1 FTE,
20 hours per week= .5 FTEs and 10 hours per week=.25 FTEs): Click here to enter text. FTEs
2. Please list the name, title, and credentials of each staff person dedicated to lactation patient care: Click here to enter text.
3. Is there a designated Lactation Coordinator who oversees lactation care within the facility? ☐ No
☐ Yes
4. Please describe the lactation coverage at your facility (i.e. 8, 12, or 24 hour coverage and # of days per week):
Click here to enter text.
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The Gift Designation
Expedited Application
Page 2
Ever Breastfed (Initiation) Rate
Numerator: Total number of infants receiving breast milk during the hospital stay
Denominator: Total number live births
Data/Statistics (Rate): Click here to enter text.
Time Period: Click here to enter text.
Exclusive Breastfeeding Rate
Numerator: Total number of infants receiving ONLY breast milk during the hospital stay
Denominator: Total number live births
Data/Statistics (Rate): Click here to enter text.
Time Period: Click here to enter text.
Joint Commission National Quality Measuresi
PC-05: Does the facility track exclusive breast milk feeding according to The Joint Commission’s definition of exclusive breast milk feeding (PC-05: Exclusive
breast milk feeding during the newborn’s entire hospitalization)?
☐ No
☐ Yes
If yes, what is that rate? Click here to enter text.
What is the time period in which you are reporting this rate for? Click here to enter text.
PC-05a: Does the facility track exclusive breast milk feeding according to The Joint Commission’s definition of exclusive breast milk feeding (PC-05a Exclusive
breast milk feeding during the newborn’s entire hospitalization considering mother’s choice)?
☐ No
☐ Yes
If yes, what is that rate? Click here to enter text.
What is the time period in which you are reporting this rate for? Click here to enter text.
Please feel free to attach any additional infant feeding related documentation for any other indicators/measures that your facility tracks.
Rev. 4/8/2014
The Gift Designation
Expedited Application
Page 3
CDC Maternity Practices in Infant Nutrition and Care (mPINC) Surveyii
2007 mPINC score (value between 0 and 100): Click here to enter text.
☐Unsure, will find out and send score after contacting the CDC
☐Facility did not complete survey
2009 mPINC score (value between 0 and 100): Click here to enter text.
☐Unsure, will find out and send score after contacting the CDC
☐Hospital did not complete survey
2011 mPINC score (value between 0 and 100): Click here to enter text.
☐Unsure, will find out and send score after contacting the CDC
☐Hospital did not complete survey
i
The Joint Commission’s Exclusive Breast Milk Feeding Measures
Performance Measure Name: Exclusive Breast Milk Feeding
PC-05: Exclusive breast milk feeding during the newborn’s entire hospitalization
PC-05a Exclusive breast milk feeding during the newborn’s entire hospitalization considering mother’s choice
Description:
PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization
PC-05a Exclusive breast milk feeding during the newborn’s entire hospitalization considering mother’s choice
The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization, and a second rate, a subset of the first, which includes
only those newborns that were exclusively fed breast milk during the entire hospitalization excluding those whose mothers chose not to breast feed.
http://manual.jointcommission.org/releases/TJC2013A/MIF0170.html
ii
Maternity Practices in Infant Nutrition and Care (mPINC)
Maternity Practices in Infant Nutrition and Care (mPINC) is a national survey of maternity care practices and policies that is conducted by the CDC. The survey is administered to all hospitals and
birth centers with registered maternity beds in the United States and Territories. The mPINC survey measures breastfeeding related policies and practices, showing facilities their strengths as well
as areas that need improvement. For more information about the mPINC survey visit www.cdc.gov/mpinc. To find out your hospital’s score email mpinc@cdc.gov.
Rev. 4/8/2014
The Gift Designation
Expedited Application
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