Roger A. Edwards, ScD Assistant Professor Bouv é College of Health Sciences

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Roger A. Edwards, ScD

Assistant ProfessorBouvé College of Health SciencesNortheastern University 360 Huntington Ave , 140 The

Fenway Building, R218Boston, MA 02115

Phone (0ffice): 617 373 8344Phone (mobile): 508 472 0406

E-mail: [email protected]

MBC Baby Friendly Collaborative – January 9, 2014Theme: Supplementation

Mary Ellen Boisvert, RN…

Nurse ManagerSouthcoast Hospital Group43 High St.Wareham, MA 02571

Phone (0ffice): 508 273 4011Phone (mobile): 508 245 0488

E-mail: [email protected]

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

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Theme for 2014: Supplementation– January 9, 2014: Root Causes

– Feb/Mar: Process Analyses and Change

– April: Experiences

– May/June: TBD

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measurement)


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A case study using fishbone diagrams illustrates the processMassachusetts Breastfeeding Coalition Baby Friendly Collaborative – 9/17/09 Theme: “Free” Formula

“There’s no free lunch” 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)

While formula industry ties have been exempt, changes in formula policies would be consistent with broader recommendations

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

Applications of CQI . . .

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Acceptance of Free Formula

We’ve done it for decades

Saves Money

Formula companies bring us perks when we do

etc…

Change takes

energy

Staff don’t like change

etc …


…

etc…

Change creates

cognitive dissonance

Value as a health

professional is derived from experience

The root causes suggest ways to overcome some of the challenges related to changing the status quo

What did we learn from the “back to sleep” campaign?

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Supplementation of breastfed

infants

We’ve done it for decades

etc…

etc…

etc…

Change takes

energy

Staff don’t like change

etc …


…

etc…

Change creates

cognitive dissonance

Value as a health

professional is derived from experience

The root causes suggest ways to overcome some of the challenges related to changing the status quo

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infants

People


…

Mothers• “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

PhysiciansNurses

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infants

People


Mothers

• 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.

PhysiciansNurses

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infants

People


Mothers

• 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

PhysiciansNurses

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infants

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

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infants

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

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infants

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)

…

Environment Procedures

People

Equipment

Limited …Lack of …

Available services

…Time

Supportive … but…

Overall …

… …

….. …

Co-located … not available Physical space

…Space

……

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Approach . . .





measurement)


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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

Context . . .

16Source: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Perinatal+Care+Core+Measure+Set.htm

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”

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)

Context . . .


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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measurement)


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Swim Lane Flow Chart example

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Swim Lane Flow Chart “Mom Needs Rest”- Pre

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Swim Lane Flow Chart “Mom Needs Rest”- Post

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Roger A. Edwards, ScD Assistant Professor Bouv é College of Health Sciences

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