MBC Baby Friendly Collaborative – January 9, 2014
Theme: Supplementation
Roger A. Edwards, ScD
Mary Ellen Boisvert, RN…
Assistant Professor
Nurse Manager
Bouvé College of Health Sciences
Southcoast Hospital Group
Northeastern University
43 High St.
360 Huntington Ave , 140 The Fenway
Building, R218
Wareham, MA 02571
Boston, MA 02115
Phone (0ffice): 508 273 4011
Phone (0ffice): 617 373 8344
Phone (mobile): 508 245 0488
Phone (mobile): 508 472 0406
E-mail: boisvertm@southcoast.org
E-mail: ro.edwards@neu.edu
1
Agenda
– Welcome and Introductions
– Planning for 2014
• Supplementation: What to Expect
– Why is there a need to supplement with formula?
• What is a Fishbone?
• Fishbone Example
– Data Sharing
• Role of a collaborative
• EBF at Discharge (Definitions-TJC criteria for measurement)
– Planning for next meeting
• Swim Lane Flow Chart: Supplementation
2
Theme for 2014: Supplementation
– January 9, 2014: Root Causes
– Feb/Mar: Process Analyses and Change
– April: Experiences
– May/June: TBD
3
Agenda
– Welcome and Introductions
– Planning for 2014
• Supplementation: What to Expect
– Why is there a need to supplement with formula?
• What is a Fishbone?
• Fishbone Example
– Data Sharing
• Role of a collaborative
• EBF at Discharge (Definitions-TJC criteria for measurement)
– Planning for next meeting
• Swim Lane Flow Chart: Supplementation
4
Applications of CQI . . .
A case study using fishbone diagrams illustrates the process
Massachusetts Breastfeeding Coalition
Baby Friendly Collaborative – 9/17/09
Theme: “Free” Formula
“There’s no free lunch”
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
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One of the core concepts of economics is
that for every benefit there is also a cost
The person who receives the benefit may not
pay or even be aware of the cost, there is a
cost paid by someone
This issue is recognized in medicine in terms
of the recent recommendations that the
health professions avoid conflicts of interest
(and perceptions of conflicts of interest that
could compromise patient care)
A fishbone (cause-effect) diagram is a CQI tool
that is used to identify, explore, and display the
causes of a particular problem
Steps in constructing a fishbone diagram:
1. Establish process facilitator and team members
2. Define problem
3. Generate main causes of the problem and sort
4. Brainstorm ideas related to the main causes
5. Interpret results from diagram
6. Identify any causes or ideas where immediate
action can be taken
While formula industry ties have been
exempt, changes in formula policies would
be consistent with broader
recommendations
5
Applications of CQI . . .
The root causes suggest ways to
overcome some of the challenges
related to changing the status quo
We’ve done it
for decades
etc …
Change
takes
energy
Staff
don’t like
change
Saves Money
Change
creates
cognitive
dissonance
Value as a
health
professional is
derived from
experience
…
etc…
Acceptance
of Free
Formula
etc…
Formula companies bring us
perks when we do
What did we learn from
the “back to sleep”
campaign?
6
Applications of CQI . . .
The root causes suggest ways to
overcome some of the challenges
related to changing the status quo
We’ve done it
for decades
etc …
Change
takes
energy
Staff
don’t like
change
etc…
Change
creates
cognitive
dissonance
Value as a
health
professional is
derived from
experience
…
etc…
Supplementation
of breastfed
infants
etc…
etc…
7
Applications of CQI . . .
Mothers
People
…
•
•
•
•
•
•
•
Nurses
Physicians
•
•
•
•
•
•
“not enough milk”
sore nipples
fatigue
FOB wants to help feed baby
baby not getting enough (fussy)
prior plan to supplement/combo feed (r/t
work/school/family responsibilities)
uncomfortable/embarrassment (not in front of
family/friends)
cultural beliefs
Misunderstanding of breastfeeding norms
Misreading newborn behaviors/cues
Acceptance by other mothers who supplemented
(vs. subtle put-down for striving for EBF)
Formula company marketing creates doubt
regarding importance/necessity to EBF
Others can help feed
Supplementation
of breastfed
infants
8
Applications of CQI . . .
People
Mothers
Nurses Physicians
•
•
•
•
•
•
•
•
•
Weight loss
Jaundice
Hypoglycemia
early gestational age (need for more calories)
Personal beliefs/experiences
It is OK/it does not matter if you supplement
Easier to recommend supplementing (so not have
to ‘worry’ about mother/baby well-being as much
Formula company marketing creates doubt
regarding importance/necessity to EBF
Mother needs sleep and it is my job to not wake
her for breastfeeding, etc.
Supplementation
of breastfed
infants
9
Applications of CQI . . .
People
Mothers
Physicians
Nurses
•
•
•
•
•
•
•
•
•
Uncomfortable with educating patients on risks of formula
supplementation
Lack of education R/T breastfeeding support
Insufficient LC support available for challenging patient circumstances
Unable to provide maternal support
Culture
Hospital practices
Personal beliefs/experiences
Easier to manage mother who is formula feeding (more predictable/less
fussy baby and less frustrated mother)—feeling good about keeping all
‘in order’
Formula company marketing creates doubt regarding
importance/necessity to EBF
Supplementation
of breastfed
infants
10
Applications of CQI . . .
Materials
• Availability of formula (have some in case I
need it)
• Formula advertising
• No access to breast pump
• Being able to see how much the baby has
consumed
• Introduction of too many “gadgets” for
breastfeeding
Supplementation
of breastfed
infants
11
Applications of CQI . . .
Environment
•
•
•
•
•
•
•
Visiting hours
Lack of support from family (FOB, grandparents)
Culture does not support breastfeeding
Mom needs rest
Delayed breastfeeding in L&D
No skin-to-skin at birth
Hospital practices take priority over promotion of
breastfeeding
• Breastfeeding is not the “norm”
• Insufficient follow-up/support after hospital
discharge
Supplementation
of breastfed
infants
12
Applications of CQI . . .
Management/Process
• Conflicting messages from staff/practitioners
• inconsistent education r/t frequency, duration, latch
• Going to OR – anesthesiologist/surgeon recommends pump &
dump
• Breastfeeding contraindicated with medication(s)
• Breastfeeding contraindicated with ordered procedure i.e.
radiology (exposure to medicine, prep/chemicals)
• Less variation because it is not as dependent on individual
characteristics of mother and baby
• You have nipple trauma justification for ‘break’ from
breastfeeding and supplementation
• Maternal illness
• Maternal anxiety
• Mother/infant separation
• History of breast surgery (supply issues)
• Prior negative experience (lack of confidence)
• Convenience of staff/more predictable timing of infant-related
activities (e.g., weighing, bathing)
Supplementation
of breastfed
infants
13
Approach . . .
Limited …
Time
…
Supportive …
but…
Overall …
…
Procedures
Lack of …
Environment
…
…
Available
services
Co-located …
not available Physical
space …
Space
…
…..
…
…
Equipment
People
14
Agenda
– Welcome and Introductions
– Planning for 2014
• Supplementation: What to Expect
– Why is there a need to supplement with formula?
• What is a Fishbone?
• Fishbone Example
– Data Sharing
• Role of a collaborative
• EBF at Discharge (Definitions-TJC criteria for measurement)
– Planning for next meeting
• Swim Lane Flow Chart: Supplementation
15
Context . . .
Required components of PC-05 include the following:
• Exclusive breast milk feeding is defined as a newborn receiving only
breast milk and no other liquids or solids except for drops or syrups
consisting of vitamins, minerals, or medicines
• TJC suggests the following sources for collecting data
– Feeding flow sheets
– Intake and output sheets
– Individual treatment plans
– Nursing notes
– Physician progress notes
– Discharge summary
Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm
16
Context . . .
Required components of PC-05 include the following:
•
Reasons for not exclusively feeding breast milk during the entire
hospitalization must be clearly documented in the medical record
– These reasons are due to a maternal medical condition for which feeding
breast milk should be avoided
•
•
•
•
•
HIV Infection
Human t-lymphotrophic virus type I or II
Substance abuse and/or alcohol abuse
Active, untreated tuberculosis
Taking certain medications, i.e., prescribed cancer chemotherapy,
radioactive isotopes, antimetabolites, antiretroviral medications and other
medications where the risk of morbidity outweighs the benefits of breast milk
feeding
• Undergoing radiation therapy
• Active, untreated varicella
• Active herpes simplex virus with breast lesions
– The mother’s refusal to feed the newborn breast milk does not
constitute a reason for not exclusively feeding breast milk
– “Reasons must be explicitly documented”
Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm
17
Context . . .
Required components of PC-05 include the following:
•
Excluded Population of Newborns
–
–
–
–
–
–
–
•
Discharged from the hospital while in the NICU
Galactosemia
Parenteral infusion
Experienced death
LOS > 120 days
Enrolled in clinical trials
Documented reason for not exclusively feeding breast milk
Sampling
– Average quarterly inpatient sample group size >= 1501 (N), then minimum
required group sample size is 301 (n)
– Average quarterly inpatient sample group size 376 - 1500 (N), then minimum
required group sample size is 20% of the Initial Patient Population Size (n)
– Average quarterly inpatient sample group size 75 - 375 (N), then minimum
required group sample size is 75 (n)
– Average quarterly inpatient sample group size is < 75 (N), then no sampling; 100%
of the Initial Patient Population Size is required (n)
Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm
18
Exclusivity calculation • # Infants who meet eligibility criteria = 40
• # Mother/Infant pairs who exclusively
breastfed = 32
32/41 * 100 = 78% Exclusive Breastfeeding
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Agenda
– Welcome and Introductions
– Planning for 2014
• Supplementation: What to Expect
– Why is there a need to supplement with formula?
• What is a Fishbone?
• Fishbone Example
– Data Sharing
• Role of a collaborative
• EBF at Discharge (Definitions-TJC criteria for measurement)
– Planning for next meeting
• Swim Lane Flow Chart: Supplementation
20
Swim Lane Flow Chart example
21
Swim Lane Flow Chart “Mom Needs Rest”- Pre
22
Swim Lane Flow Chart “Mom Needs Rest”- Post
23