Team Ontario Baby Friendly Initiative Evaluation...

Team Ontario – Baby Friendly Initiative Evaluation Plan 1

Team Ontario Baby Friendly Initiative

Program Evaluation Plan

MHST 606

March 24, 2013

Dianne Pletz, Megan Hiltz

Shayiza Vellani, Ann Turcotte


Introduction WHAT IS THE BABY FRIENDLY INITIATIVE?

The Baby-Friendly Initiative (BFI) is a global program established by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 to improve breastfeeding outcomes for mothers and babies. The BFI is inclusive of all babies and families, regardless of feeding method. Breastfeeding is an important contributor to infant and child health. Research demonstrates that breast milk is the optimum nutrition for healthy development and provides biological protection against disease and illness for both mother and child. The World Health Organization, Health Canada, and the Canadian Pediatric Society recommend exclusive breastfeeding for the first six months of a child’s life, with continued breastfeeding in addition to age-appropriate solid foods for two years and beyond.

Health care providers within a Baby-Friendly-accredited setting have the responsibility to ensure that families receive all the education they need to make informed decisions regarding how to feed their child. The Baby-Friendly designation may be pursued by either community health services or by hospitals as a means of ensuring the delivery of infant feeding services to the public meet a high standard. A Baby-Friendly facility helps women to successfully initiate and continue to breastfeed their babies, and receives recognition for having done so. Mothers who make the informed decision not to breastfeed for personal and/or medical reasons are supported in their decision and educated to provide breast milk substitutes in a safe and nurturing manner. The Baby Friendly Initiative is a continuous quality improvement strategy and is reviewed and updated regularly in order to promote evidence based practice in the care of mothers and babies.

The BFI ensures consistent care, information and advice is provided to pregnant women and nursing mothers. The BFI promotes the early initiation of breastfeeding and skin to skin contact between mother and baby initiated immediately after birth to encouraging the instinctive seeking and suckling behaviours. When mother and baby need to be separated the mother is helped with expressing her milk and the expressed milk is given to the baby. No food or drink other than breast milk is given to newborns nor are artificial nipples or pacifiers given, the mother is given full authority for her own resource, breastfeeding. Staff in maternity and pediatric units have a written policy, which they understand and follow to ensure consistent and skilled help and support with breastfeeding.

10 Steps to Successful Breastfeeding

The "Breastfeeding Committee for Canada (BCC) BFI Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services" describes the international standards for the WHO/UNICEF Global Criteria within the Canadian Context. Based on experience with the implementation and assessment of the BFI in Canada, the BCC developed the 10 Step Practice Outcome Indicators in 2004.To be designated as Baby-Friendly an institution needs to ensure the outcome indicators have been achieved 80% of the time. The 10 Steps Practice Outcome Indicators include the following:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff, volunteers, women and their families.

2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate skin-to-skin contact immediately after birth and assist with breast feeding

within an hour after birth.


5. Show mother's how to breastfeed and how to maintain lactation even if they should be separated from their babies.

6. Give newborn infants no food or drink other than breast milk unless medically indicated. 7. Practice 24-hour rooming-in. Mothers and infants remain together from birth. 8. Encourage breastfeeding on demand and encourage baby-led or cue-based feeding. 9. Give no artificial nipples or pacifiers to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on

discharge from the hospital.

The WHO Code seeks to further protect breastfeeding by ensuring the ethical marketing of breast-milk substitutes by industry. Compliance with the International Code of Marketing of Breast-Milk Substitutes includes the following:

1. No advertising of formula, bottles, nipples, pacifiers to the public. 2. No free samples of the product to mothers. 3. No promotion of artificial feeding products in health care facilities, including the distribution of

free or low-cost supplies. 4. No company representatives to advise mothers. 5. No gifts or personal samples to health workers. 6. No words or pictures idealizing artificial feeding, including pictures of infants on the labels of

products. 7. Information to health workers should be scientific and factual. 8. All information on artificial infant feeding including the labels should explain the benefits of

breastfeeding and he costs and hazards associated with artificial feeding. 9. Unsuitable products such as sweetened condensed milk should not be promoted for babies.

In 2009 the Ontario Ministry of Health and Long-Term Care (MOHLTC) requested that the Provincial Council for Maternal and Child Health (PCMCH) establish an expert panel tasked with providing cost-effective recommendations and options to support the delivery of breastfeeding supports and services in Ontario with a focus on improving breastfeeding initiation, duration and exclusivity rates. Two of the expert panel’s recommendations are focused on increasing initiation, duration and exclusivity rates through:

1. Working towards implementation of the BFI which as previously noted is a global evidence-based standard of care demonstrated to increase breastfeeding rates by promoting, protecting and supporting breastfeeding.

2. Implementation of breastfeeding educational programs appropriate to the roles/responsibilities of healthcare providers, administrators, decision makers and volunteers in hospitals, Public Health Units and Community Health Centres about policies and practices needed to promote, protects and support breastfeeding.


Effective January 2012, Accreditation Canada is now referencing BFI practices in its Obstetrical standards for hospitals. Currently several requirements have corresponding guidelines referencing staff education and training specific to breastfeeding and have evidence-based infant feeding policy that aligns with the BFI and the International Code of Marketing of Breast-milk Substitutes which are as follows:

1. A comprehensive organizational infant feeding policy which is evidence-based and aligned with the WHO/UNICEF BFI and its Canadian adaptation.

2. Ensuring the team’s staff, service providers and volunteers are educated, trained, qualified and competent.

3. Facilitating mother/baby dyad care - the team supports immediate (within the first five minutes) and sustained (for at least one hour) skin-to-skin contact following vaginal or C-section birth. The team supports and monitors skin-to-skin contact, and provides bedside care to the mother/baby dyad on a one-to-one basis.

4. Client education that supports the independent care for mother and baby after service has ended.

5. The team considers the clients' and families' beliefs, values, culture, literacy, language, and functional abilities, and also respects their choices about what they want to learn.

6. Education is provided to parents on the importance of immediate and sustained skin-to-skin contact; early initiation of breastfeeding; manual expression of breast milk; for infants fed breast milk substitutes, education about the appropriate formula, preparation, and storage; feeding on-cue or baby-led feeding; frequent feeding to help maintain enough milk; good positioning and attachment; rooming-in on a 24-hour basis; infant crying and consoling techniques; proper infant sleeping position; childhood immunization; how to reduce unintentional injuries, and how to recognize signs of jaundice

Background – Lakeside Hospital Maternal Child Program Lakeside Hospital is a Level IIb regional birthing centre. A Level IIb birthing centre is defined by the PCMCH and delivers babies as early as 32 weeks in gestational age and a birth weight of greater than 1500 grams. Lakeside hospital has a fully resourced Intensive Care Nursery (ICN) to provide care to pre-term and low weight neonates. Pre & Post-Natal care is provided by a team of Obstetricians, Midwives, Nurses and Pediatricians, the average number of births per year is 800-900.

A recent review of Lakeside Hospital's performance outcome metrics noted that while breastfeeding initiation rates are high 88% immediately after birth while in hospital, breastfeeding significantly decreases to 30% at 6 months. The BFI is an important strategy in fostering an environment that supports and promotes exclusive breastfeeding. The overarching goal of this evaluation plan is to determine the strategies required to increase exclusive breastfeeding rates at birth and support new mothers to exclusively breastfeed for 6 months with continued breastfeeding for 2 years and beyond.

In May of 2012 the CEO and VP Clinical Services endorsed their full support for Lakeside to fulfill the requirements to achieve Baby Friendly Status. Lakeside is also preparing for an upcoming accreditation process in September 2013. Currently at Lakeside only 58% of babies are being exclusively breastfed upon discharge, with another 30% a combination of breast and formula supplementation and a remaining 11% who are exclusively formula fed. This is the latest information on the Better Outcomes Registry & Network Ontario (BORN) dashboard.


In developing a successful BFI program, stakeholder participation and collaboration is imperative in the development of innovative strategies to provide women with breastfeeding education and support across the peri-natal continuum. Key stakeholders in the BFI include: pregnant mothers and their partners, front-line nursing staff, lactation consultants (in hospital and public health), hospital management, obstetricians and gynecologists (OB/GYNE), midwives, Pediatricians and the local Public Health Unit (PHU).

Objectives: After reviewing the information provided the learner will be able to:

1. Define what the Baby Friendly Initiative (BFI) is, including a description of the program, the goals and objectives of the BFI.

2. Describe how BFI can be implemented, including the 10 step plan practice outcome indicators. 3. Describe the purpose of the evaluation, specific data collection methods, and data sources

produced in the evaluation of the BFI. 4. Highlight key components of the logic model. 5. Identify key components of the Data Collection Matrix. 6. Provide a brief description of the data analysis.

Purpose of Evaluation The BFI is a complex, multifaceted program to optimize breastfeeding support by transforming health service structures, processes, and practice. According to the latest report released by the BCC (2012) only 35 hospitals in Canada have received Baby Friendly designation with the majority (20) of those being in the province of Quebec. Lakeside's goal of implementation of the BFI program is to achieve the Baby Friendly Designation. In order for this to happen the hospital has to meet the target of 80% exclusive breastfeeding for all healthy babies and meet the criteria set out in the BFI 10 Steps Practice Outcome Indicators. The purpose of this evaluation plan to ensure Lakeside is in compliance with the 10 Step Outcome Indicators to meet the standards required to achieve the Baby Friendly Designation. To accomplish this a comprehensive needs assessment will be completed to determine what practices are in place at Lakeside that are in compliance with the standards and what gaps currently exist. Upon completion of the needs assessment the Maternal/Child team will develop an action plan that will ensure success in meeting the BFI standards. The process of achieving the Baby Friendly Designation includes the following:

1. Declare the organization’s intention to pursue BFI Designation. 2. Completion of a self-appraisal using the BCC BFI Integrated 10 Steps Practice

Outcome indicators. 3. Develop an action plan to address the indicators that are not being met or require more work. 4. Once the self-appraisal standards have been met a pre-assessment contract and fee is

submitted to the BCC BFI Assessment Committee. 5. Any supporting documents and/or evidence of compliance is forwarded to the BCC BFI lead

evaluator. 6. If criteria have been met, a site visit will be completed through the BCC.


7. The lead evaluator will then compile a report to be review with the management team to review the recommendations.

8. If the criteria is met the Baby Friendly Designation will be awarded, this designation will be valid for a period of 5 years.

9. If the criteria has not been met the organization will receive a BCC BFI Certificate of Commitment with a list of recommendations to address the criteria that has not been met.

10. To maintain Baby-Friendly Status – ongoing self-monitoring reports will be reported annually to the BCC BFI Committee, a status report will be sent to the BCC BFI every 2 years with a reassessment required at year 5.

Program evaluation is a systemic methodology in which information is collected regarding the activities, characteristics and/or outcomes of the program that determines the adequacy of the program, make improvements to a program as well as make decisions about the future of the program (Preskill & Catsambas, 2006). The ultimate outcome of stakeholder participation in the BFI evaluation process is the organizational learning that will naturally follow. In this way evaluation serves to build and sustain a spirit of inquiry in which learning will take place incrementally and iteratively over time. The purpose of this formative and summative evaluation is to determine if the BFI is effective in promoting the importance of participation and collaboration among the various stakeholders in order to ensure adequate development and integration of breastfeeding education and maternal/newborn support. The target group for the BFI are pregnant mothers, their partners as well as medical and nursing staff who support new families through this process. From a formative standpoint, the evaluation will describe changes to the program. This will enable program managers and policy makers to create an action plan that can enhance program effectiveness. From a summative standpoint, the evaluation will provide key stakeholders with a general picture as to the overall merit or worth of the program and whether or not it should continue to operate.

Ghost Theorist - Hallie Preskill Hallie Preskill’s evaluation theory fits in quite nicely with the development of the BFI at Lakeside. Her evaluation theory is predicated on the active relationship between evaluators and intended users and the collaborative and participatory approaches that occur as part of the evaluation process. Participatory approaches involve the inclusion of stakeholders in the program design and data collection process. The premise being that when stakeholder involvement in the evaluation process is high, the end result is greater stakeholder buy-in to the program, understanding of the program process and design and the ultimate use of the evaluation findings. By taking this approach, stakeholders learn from each other, gain greater insights, knowledge and experience needed for problem solving and managing the organizational change as the BFI is implemented across the Maternal Child Program at Lakeside (Torres & Preskill, 2001).


Data Collection Methods The Logic Model (see Appendix #3) is the foundation for the data collection matrix. It portrays the depiction of the program theory utilized in the form of a framework. Our BFI logic model lays out the sequence of events which initially address the services to be provided and concludes with the target group outcomes based on the BFI program. The logic model is a graphic depiction of its six components which are: Inputs, Activities, Outputs, and Short-term, Intermediate and Long-term Outcomes. Inputs can be considered the resources and constraints applicable to the program. Activities can be considered the services to be provided by the program. Outputs refer to the receipt of services by the target group. Outcomes are the objectives that are desired by the program and have time frames associated with each one. Each of these components build on the previous component and goes from being specific to broad as you move from inputs to outcomes. Our logic model is based on the completed needs assessment. Under each component is a list of topics that will need to be reviewed and assessed. The creation of the logic model leads to the development of the data collection matrix or DCM for short. The Data Collection Matrix (DCM) (Appendix #4) is another framework and/or roadmap to further guide the evaluator in the evaluation process. The DCM is comprised of four components which are: evaluation topics, evaluation questions, indicators and data sources/tools. The DCM follows the logic models primary components as well as the topics listed under each one. The evaluation topics are the areas requiring review, the evaluation questions section is comprised of questions to ask related to the topics, indicators will tell the evaluator the required information to answer the question and finally the data sources/tools identify where the evaluator can look for data collection. It too is also based on the completed needs assessment. The evaluation topics identified in the logic model are used to develop the evaluation questions to be asked during the evaluation process. It is these questions that help to identify the strengths, weaknesses, influence and effectiveness of the BFI at Lakeside Hospital.

BFI Data Sources

BORN Indicator Report

BORN grew out of the five founding members that comprised the Ontario Perinatal Surveillance System (OPSS) which included the Ontario Maternal Multiple Marker Screening, Fetal Alert Network, Ontario Midwifery Program, Niday Perinatal Database and Newborn Screening Ontario. The data has been integrated into one accurate and timely maternal-child registry to form the authoritative information system needed to realize BORN Ontario’s vision. The information gathered will support the MOHLTC, the PCMCH, Local Health Integration Networks (LHINs) and PHUof Ontario in measuring maternal-child health status and outcomes, developing responsive health policies and improving evaluation and accountability. Hospitals and midwifery groups, as well as Provincial Screening Programs, will leverage the information for planning, monitoring, performance management and quality improvement. As with any hospital in Ontario that delivers maternal-child services, Lakeside submits information to the BORN. This web based registry supports the continuum of care through from the initial point of contact with a pregnant woman, health indicators are screened during the various phases of maternal/child care.


For the purpose of the BFI the following indicators will be tracked through BORN:

total births/year

% of healthy babies exclusively breastfeeding or receiving only human milk - goal =75-80%

% babies breastfeeding with formula supplementation

breastfeeding initiation rate

exclusivity rate

duration of breastfeeding a 2, 4, 6, 12 months

% of births in which skin to skin contact was initiated within 1/2 hour of birth

% of births in which breastfeeding was initiated within 1 hour of birth

% of mom/baby dyads rooming

latch scores

Document Management System (DMS) Lakeside Hospital

Lakeside Hospital has an electronic DMS which houses all Policy and Procedures. The updated breastfeeding policy will be placed on the DMS once completed. At that point an electronic notice is sent out to all staff working on the Mat/Child unit to review the updated policy. Once the policy has been reviewed by the nurse, she/he can update the program to indicate the policy has been reviewed. This serves as an internal audit tool for the manager to track who on the unit has reviewed the policy.

Lakeside Electronic Health Record This is an audit tool to track the number of referrals to Lactation Consultant.

Staff Surveys (Appendix 1) Surveys will be conducted via the Registered Nurses Association of Ontario (RNAO) Online education program.

Mother Satisfaction Surveys (Appendix 2) Patient surveys will be conducted via the NRC Picker Canada.

Public Health Unit Indicator Report Indicators to track rates of ongoing breastfeeding at 2,4,6 & 12 months via follow-up phone calls


Data Collection Methods and Limitations

Method Description Limitations Key Stakeholder Interviews The stakeholder is asked questions by the evaluator. Qualitative questions are opened ended providing questions that are exploratory in nature and consists of a variety of questions. Quantitative questions are closed ended questions.

More expensive than questionnaires Dependent on rapport built between interviewer and interviewee Possibility of evaluator bias; interviewee providing answer evaluator may want to and consists of a variety of questions Interviewee may be lead to specific answers through probing questions

Questionnaires/Satisfaction Surveys List of survey or research questions developed through both open and closed ended questions.

Poor response rate Questions are standardized which leaves room for misinterpretation May be too short therefore unable to extract appropriate information or may be too long for respondents to answer questions. Data analysis is time consuming an expensive.

BORN Indicator Reports Web based dashboard that allows for tracking of key performance indicators. Reports are provided to hospitals on a monthly and quarterly basis.

Examination of long-term trends may be difficult depending on when data was captured. Training required for all staff inputting data into BORN Time required to review variances and maintain data quality

Lakeside Document Management System (DMS) Lakeside hospital has an electronic DMS which houses all policy and procedures. This serves as an internal audit tool for the manager to track who has reviewed updated policy and procedures.

Cost in creating and maintaining audit tool Initial training required for all users Cost implications of software updates

RNAO On-Line Education Program – this course is based on RNAO’s Breastfeeding BPG’s and is free of charge to all practicing nurses.

Time availability of staff to complete the online program Staff compliance with completion of the course

NRC Picker Canada (NRC) This is the pre-eminent national provider of healthcare measurement and improvement solutions across the continuum of care. NRC Picker’s research demonstrates the interactive relationship between the perceptions and experiences of employees, physicians and the patient experience.

Poor response rate Patient bias due to physician expectations Cost to the organization

Public Health Unit (PHU) Indicator Report Follow-up rates of breastfeeding are captured via telephone survey at 2,4,6 & 12 month intervals.

Insufficient sample size to stratify data Poor response rate Mothers experiencing negative feelings towards herself if unsuccessful in sustaining breastfeeding


Data Analysis

Patton (2008) suggests that before any concrete data analysis can be conducted, the recommendation for a simulation of data analysis should occur. This practice will allow for the identification of all data that will be used in the evaluation. In this simulation exercise, key stakeholders will engage in hypothetical scenarios that will prepare them for the various outcomes presented by the data analyses. Patton (2008) suggests utilizing the ‘Framework for Engaging Findings’ which consists of 4 steps once the data has been gathered and formalized for data analysis. Basic Finding Description and Analysis:

Organizing qualitative data obtained from assessment tools, case management reviews, gathering coordination of care data, and data gathered from satisfaction surveys from the education model. This is done through sorting or theming of key stakeholder, questionnaires and focus group raw qualitative data. Quantitative data will be measured through the BORN dashboard performance indicators (as previously described in the BFI data sources). Interpretation:

Validate assessment tool data and case management reviews with clients to ensure they are provided with the appropriate education regarding the BFI and are placed in the appropriate setting. This is accomplished by working with stakeholders to provide context to the data, and facilitate stakeholder interpretation of the data. The BORN performance indicators will be analyzed to determine whether or not the program met the intended goals of reaching 80% compliance with the 10 Steps Practice Outcome Indicators

Judgement:

Through client satisfaction surveys, the data gathered regarding the development of education around BFI and if learning was adequate in assisting clients will be assessed to analyze if the short-term, intermediate and long-term outcomes were satisfied. In this particular step, value is placed on certain data over others.

Recommendations:

The information gathered for this particular evaluation will be based on both summative and formative elements. The analysis of this data will inform both the summative and formative processes, which in turn will benefit both staff and clients. This step is dependent on the action by-product of data analysis.


BFI Needs Assessment and Recommendations As part of achieving the Baby Friendly Designation, a comprehensive self-appraisal process has to be completed using the BFI indicators to assess the degree to which current practices at Lakeside align with the 10 Steps. This is the basis for determining the current state and the development of the BFI program. During this assessment the following issues were identified: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff, volunteers, women and their families. It was discovered that the current policy was outdated, no process established for staff to routinely review the policy and document that the review was completed. Recommendation:

To completely update the current breast feeding policy, integrate the 10 Steps and Breastfeeding Best Practice Guidelines (BPG’s) per the Registered Nurses Association of Ontario (RNAO). The policy will serve to protect breastfeeding (BF) by prohibiting all promotion of breast milk substitutes, feeding bottles and pacifiers on the Mat/Child unit.

There will be an established process for staff to review the policy on an annual basis, through the DMS. Once the policy has been reviewed staff can document this review has occurred and compliance audits can be completed by the unit manager.

2. Train all health care staff in skills necessary to implement this policy. All staff on the unit are oriented to the breastfeeding policy, however not all staff have had the required training at this time. Recommendation:

All staff will be made aware of the breastfeeding policy and the philosophy and mandate to support breastfeeding on the Mat/Child unit.

All training will be evidence based and facilitated by the Lactation Consultant (LC) and Nurse Educator of the Mat/Child Program. Education will include the RNAO’s Breastfeeding online e-Learning course. Feedback regarding the efficacy of this course will be obtained through staff satisfaction surveys.

Ongoing training, updates and continuing support will be provided to staff via the LC as well as guest speakers from the regional peri-natal program.

3. Inform all pregnant women about the benefits and management of breastfeeding. All pregnant women who are planning to give birth and are being delivered by the OBS team at Lakeside are pre-screened in the Ante-natal Clinic. This incorporates 80% of the total births at Lakeside. The other 20% of births are through Midwife care. Midwives are represented on the Mat/Child Interdisciplinary Team and follow the same practice guidelines as the hospital staff. There is a gap in the continuity of care from the PHU to Lakeside in the ante-natal period and from Lakeside to the PHU post-natally in terms of breastfeeding education and community follow-up. Recommendation:

Collaboration with PHU partners - with the BORN registry, Lakeside staff are now able to access all information recorded in the BIS which includes documentation by PHU. Likewise the PHU can access information from Lakeside. The PHU has been mandated to implement the BFI in the community. Initiation of breastfeeding remains high in hospital but drops off significantly at home.


Any woman who has never breastfed or who has previously encountered difficulty with breastfeeding will be given support from staff and LC when in hospital, as well an appointment with the PHU LC is arranged prior to patient being discharged from the Mat/Child Unit.

All pregnant women attending the Ante-natal clinic will have a breast assessment by the LC in an effort to identify and/or anticipate any potential issues that may impact upon successful breastfeeding.

All advertising by formula companies is prohibited within the hospital, however it is still present in reading materials in the OB Clinic. All steps will be made to remove this material.

Mothers will be surveyed post-natally to determine the efficacy of the breastfeeding education. Measure indicator sustained breastfeeding rates through the BIS.

4. Help mothers initiate breastfeeding within ½ hour of birth. Skin to skin contact is to be initiated immediately after birth for all deliveries of normal health infants. This practice has been widely accepted by the WHO as an essential aspect of newborn care. This is not common practice on the Mat/Child unit as staff report there is not enough staff to facilitate this and the preference is to complete all of the newborn assessments on the baby warming unit. Pregnant women who deliver by Caesarean Section are routinely separated from their babies after birth, babies are taken to the ICN for close observation for up to 12 hours after birth and mothers recover post-operatively in the Post-Anesthetic Care unit. Recommendation:

Staff education regarding the evidence of the importance of immediate skin-to-skin contact immediately after birth. Staff will be taught the process to complete their newborn assessments while skin-to-skin care is maintained and breast-feeding is initiated.

Skin-to-skin care will be maintained for 2 hours in immediate post-partum period. Develop a plan to recover mother baby dyad post C-section in the L&D area where skin-to-skin

contact can be initiated and maintained. This will require buy-in from the Dept. of Anesthesia and OBS.

Mothers will be surveyed post-natally to determine satisfaction with post-natal skin-to-skin contact and initiation of breastfeeding.

Skin-to-skin contact and initiation of breastfeeding is to be initiated within the first ½ hour of birth, if not, this is documented through the BIS. Rates of skin-to-skin contact will be measured and audited.

5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. Latch scores are documented twice daily, staff assess the mothers to ensure they are in correct position and babies are effectively latching to the breast. If there are issues with latching the LC will provide further assistance to the mother. Mothers are taught to hand express breastmilk as well as pump. Breast pumps are available in the hospital’s retail pharmacy for purchase. Any mother who is encountering issues with latching or otherwise is referred to the PH LC for ongoing support. Not all staff are adequately trained to support mother’s with breastfeeding issues in the absence of the LC. Recommendation:

Ongoing education to teach staff to support mother’s with hand/pump expression of breast milk.

Monitor number of referrals made to PH to ensure follow-up care is being completed to support new mothers.

Latch issues can be tracked through BIS.


Mother’s will be surveyed post-natally to determine the efficacy of breastfeeding support in hospital.

6. Give newborn infants no food or drink other than breastmilk unless medically indicated. Formula supplementation rates remain high, this is tracked through the BIS. Currently only 58% of the patient population is exclusively breastfeeding upon discharge. Recommendation:

Formula contract is now expired and will not be renewed in 2013. Formula will be ordered and available on the unit in limited quantities.

Staff will be provided further education to support BPG and will encourage hand expression of breast milk and subsequent cup or syringe feeding of expressed breast milk to babies. This will apply to all infants unless medically contraindicated.

All mothers will be taught the risks of formula supplementation; this will be supported by the PHU upon discharge from hospital.

Survey staff to determine efficacy of breastfeeding education. Monitor and audit supplementation rates through BIS.

7. Practice rooming in, allowing mothers and infants to remain together 24 hours per day. All mother/baby dyads remain together unless medically contraindicated. If infant needs to be cared for in the ICN, mother has open access and is encouraged to be with baby. There is no need to address this step. 8. Encourage breastfeeding on demand. Feeding on demand is encouraged for all mothers. Mothers are taught to respond to babies cues for feeding and are encouraged to feed in response to the baby. There are no set feeding schedules on the Mat/Child unit. Observed barriers include multiple visitors which may interrupt feeding on demand. Recommendation:

Reinforce/educate baby’s feeding cues with mothers (parents). Information posted in all patient rooms re: feeding on demand and how much the baby will

realistically be able to tolerate. Follow-up care encouraged via the PHU LC and community supports upon discharge from

hospital. Monitor and audit feeding compliance via BIS. Survey staff and mothers to determine the efficacy of breastfeeding education.

9. Give no artificial teats or pacifiers to breastfeeding infants. Staff do not give artificial teats or pacifiers to breastfeeding infants. Mothers are taught not to give artificial teats or pacifiers to their infants until breastfeeding is established and provided with the evidence that supports this rationale. This is also supported by PH through pre-natal education programs as well in the post-natal period. All pacifiers have been removed from the Gift Shop. Use of pacifiers can be tracked through the BIS. 10. Foster the establishment of breastfeeding support and refer mothers to them on discharge from the hospital. All mothers are given educational materials to support continued breastfeeding in the home. Local PH unit conducts breastfeeding clinics twice weekly. All mothers are encouraged to utilize this resource. All mothers are followed up with a 48 hour phone call and/ or in home visit from the PH LC. Mothers are


referred to the local LaLeche League for ongoing support. Recommendation:

Follow-up care to be tracked through the BIS. Survey all mothers to determine efficacy of follow-up supportive care.

Summary and Implications of Formula Supplementation and Pacifier Use Summary

Breastfeeding, although a natural process, does not come naturally to all mothers and infants. It is a learned skill. With the appropriate support, most mothers can initiate and continue breastfeeding as long as it is mutually desirable. It is important for mother and infant health care providers to understand the barriers to successful breastfeeding, and to develop the skills to support women in their desire to breastfeed. Given the health, social and economic advantages that breastfeeding confers for mothers, children and society in general, breastfeeding is a critical public health initiative. Health care professionals caring for infants and their mothers must recognize the importance of breastfeeding and strive to transfer that knowledge to the families they work with (Canadian Paediatric Society, 2012). The BFI facilitates the promotion, protection and support of breastfeeding and has been proven to be an effective tool to increase breastfeeding initiation, duration and exclusivity. This program is contingent upon the collaborative relationship and sharing of information with the Public Health Unit (PHU) as the PHU provides the ongoing support to mothers post-discharge from hospital and continued follow-up during the first 12 months after birth.

Formula Supplementation The literature regarding breastfeeding is extensive. In recent years, our knowledge of the benefits of breastfeeding has rapidly expanded. So, too, has our knowledge about difficulties that arise with breastfeeding and the appropriate management of these situations. One of the most common difficulties in sustaining breastfeeding is a perceived lack of milk. Many women discontinue breastfeeding because they are concerned for their infant’s well being, and feel that formula may be a better option to promote adequate neonatal growth. It is important for health care providers to communicate expectation of infant weight gain and maternal milk supply, prior to the postpartum period. New mothers should know in advance that breastfed infants may lose weight in their first week of life. They should also be warned that the milk supply, while low for the first few days, is adequate to meet their infant’s needs. In addition, the principle of supply and demand should be reinforced prior to delivery, and reinforced during the postpartum period. There are inherent risks associated with formula supplementation that all breastfeeding mothers should be aware of:

Formula is harder to digest for a new baby, it stays in the stomach longer than breast milk, which may cause a baby to feed less often and could cause a decrease in mother’s milk production.

Supplementing with formula, especially from a bottle, may change a baby’s suck pattern at the breast.


Latching the baby to the breast may be more difficult after a baby is fed with a firmer bottle nipple or feeds with the faster flow from a bottle.

Mother’s milk supply does not get established or decreases if she supplements with formula feeding

Babies who receive formula supplements are more likely to require an increasing amount of formula

Mothers and babies supplement with formula in the first few weeks of breastfeeding are at a greater risk to stop breastfeeding

Pacifier User

According to the Canadian Paediatric Association (2003), pacifiers have been implicated in the early weaning of healthy term breastfeeding infants. It is not recommended to offer pacifier’s to infants during the first few weeks after birth when a nursing mother’s milk is becoming established. Infants suck differently from a pacifier than from mother’s breast and babies can often find it difficult to go from breast to pacifier, which in turn can cause inefficient sucking at the breast further perpetuating decreasing milk production. La Leche League International (n.d.) recommends that pacifiers never be used as a substitute for the mother’s breast or comforting. However, they also state that pacifiers can be of help to a breastfeeding mother when used judiciously, for short periods of time and in limited circumstances

DISCUSSION QUESTIONS

1. Given that the Program Implementation team believes in and supports the Baby Friendly Initiative (BFI) what effect does this bias have on the evaluation? Which one of the American Evaluation Association Guiding Principles would benefit the evaluation team the most?

2. Can you suggest one thing that would benefit the BFI Program in the evaluation plan that we may not have addressed?

3. According to the information provided, how effective do you feel this evaluation plan is? Does this plan meet the goals of assisting in the development of a BFI program that can be successful and sustainable?

Scenario Using the brief scenario listed below, please provide your ideas on how the evaluation process can help capture information from mothers that will assist with program improvement to address situations that are out of the norm. Mary is new to the area and was not intending to deliver at Lakeside but she went into labour a few weeks early and did not have time to travel back to her intended hospital. She did not attend an antenatal clinic and staff quickly provided education during the short labour and delivery. Mary is struggling with breast feeding and has had her husband bring in pacifiers and formula.


Resources

RNAO's Breastfeeding e-Learning Course

This e-Learn was created as a means to assist nurses, other health-care professionals and organizations to access education that is appropriate to their role in promoting breastfeeding. As such, it aims to develop the knowledge, skills and attitude required to implement internationally recognized best practices in breastfeeding to create a baby-friendly environment. To accomplish this, this e-Learn has been created as an amalgamation of the Registered Nurses Association of Ontario (RNAO's) Breastfeeding Best Practice Guideline, the WHO/UNICEF Baby-Friendly Hospital Initiative's 20-hour course for maternity staff, and the Breastfeeding Committee of Canada's (BCC) Integrated 10 Steps Practice Ontario indicators for Hospitals and Community health Services.

Cost of Evaluation

Cost evaluation is a tool to help discover and choose the appropriate and most cost effective alternatives to assist in the design and implementation of efficient programs. When determining the cost of an evaluation there are a number of factors to take into consideration. An example is that cost evaluation can assess the gains and costs of carrying out a set of activities (World Health Organization, 2000). In creating an estimate to conduct a cost analysis for the evaluation, one must also take into consideration the cost for data collection, analysis tools, and methodology. The marketing and communication plan budget also needs to be taken into consideration. Data Collection, Analysis Tools, and Methods The evaluators will have access to their own software in order to conduct their methods of analysis. For this particular cost component, evaluators will need to liaise with staff in order to retrieve and collect program information, client records, and case management information. Marketing and Communication The cost for producing reports and printing will be included in the evaluation costs. In addition, any resources or mediums used for marketing this program will be added.


Lakeside Baby Friendly Initiative Budget March 2013

BCC Hospital Assessment

Pre-Assessment Contract $ 100.00

BFI Pre-Assessment Document Review $ 500.00

Honorarium for Lead Assessor @ $500.00/day X 2 days $ 1,000.00

Honorarium for additional Assessor @ $350.00/day X 2 days $ 700.00

$50.00 per diem/Assessor X 2 Assessor X 2 days $ 200.00

Travel and Accommodation for Assessment Team $ 3,000.00

Administration Fee for External Assessment Contract $ 400.00

Total $ 5,900.00

Staff Training Costs

RNAO BPG Online Course No Cost

Course content completed within working time or can be accessed at home No Cost


References

Baby Friendly Initiative Ontario www.bfiontario.ca

Breastfeeding Committee for Canada www.breastfeedingcanada.ca

Canadian Paediatric Society. (2003). Position Statement: Recommendations for the use of pacifiers.

http://www.cps.ca/documents/position/pacifiers

Canadian Paediatric Society. (2012). Position Statement: The Baby-Friendly Initiative: Protecting,

promoting and supporting breastfeeding. http://www.cps.ca/documents/position/baby-friendly-

initiative-breastfeeding

LaLeche League International www.lalecheleaguecanada.ca

Patton, M.Q., ( 2008). Utilization-Focused Evaluation. (4t ed). Sage Publications; Thousand Oaks; CA.

Preskill, H. & Catsambas, T. (2006). Reframing Evaluation Through Appreciative Inquiry. Sage

Publications Inc.

Provincial Council for Maternal and Child Health (PCMCH). Mother-BABY Dyad Care Implementation

Tool Kit Skin to Skin. www.pcmch.on.ca

Torres, R., & Preskill, H. (2001). Evaluation and Organizational Learning: Past, Present and

Future. American Journal of Evaluation. 22(3), p. 387-95. DOI:10.1177/109821400102200316.

World Health Organization. Baby Friendly Initiative www.who.int/topics/breastfeeding/en

http://www.bfiontario.ca/

http://www.breastfeedingcanada.ca/

http://www.cps.ca/documents/position/pacifiers

http://www.cps.ca/documents/position/baby-friendly-initiative-breastfeeding

http://www.cps.ca/documents/position/baby-friendly-initiative-breastfeeding

http://www.lalecheleaguecanada.ca/

http://www.pcmch.on.ca/

http://www.who.int/topics/breastfeeding/en


Appendix #1

Lakeside Baby Friendly Initiative (BFI) Staff Satisfaction Survey

Lakeside has initiated the WHO Baby Friendly Initiative. As a staff member who has participated

in the education and implementation of this program, we would like your feedback. The

education program has been developed to provide you with the information you require to

implement the interventions with each mother. Your feedback will help us improve the

program. Participation in this survey is voluntary. If you have any concerns about this survey

please contact Lakeside Communications Department at 1-800-800-0000. Please return the

survey in the envelope provided.

Please rate your level of satisfaction with: # Question 1-

Very dissatisfied

2-Dissatisfied

3-Neutral

4-Satisfied

5- Very

Satisfied

N/A

1 The BFI Program, Policy, and mandate

2 The staffing model and the time you have for the interventions of the BFI Program.

3 Your ability to establish an effective care plan for each mother .

4 Your ability to educate mothers on breastfeeding.

5 Your ability to assess newborns and establish skin-to-skin contact while performing the newborn assessment.

6 Your ability to encourage mothers to participate in no supplementation.

7 Your ability to discourage artificial pacifiers.

8 Your ability to educate mothers on sustaining breast feeding through manual expression

9 Your ability to refer mothers to services on discharge

10

Your overall satisfaction with the BFI Program and the service you provide to mothers and babies

Please provide any comments on your experience with the BFI Program in this space provided:


Appendix #2

Lakeside Baby Friendly Initiative (BFI) Mother Satisfaction Survey

Lakeside is committed to providing the best possible, safest care for your baby and is supporting the WHO Baby Friendly Initiative. We would like to invite you to fill in this survey and provide us with feedback on your experience with this breast feeding initiative. This feedback will help us improve the program. Participation in this survey is voluntary. If you have any concerns about this survey please contact Lakeside Communications Department at 1-800-800-0000. Please return the survey in the envelope provided.

Tell us about your visit with Lakeside:

Please provide us with your age: __________ 1. Were you seen in the Antenatal Clinic? ___Yes ___ No

If not, please tell us why _______________________________________________________________________

2. What was your length of stay at Lakeside? ___days 3. Did you deliver vaginally? ___Yes ___ No 4. Is this your first birth? ___Yes ___ No

Please rate your level of satisfaction with: # Question 1-

Very dissatisfied

2-Dissatisfied

3-Neutral

4-Satisfied

5- Very

Satisfied

N/A

1 The education received in the antenatal clinic.

2 Staff in the antenatal clinic were encouraging, supportive, and helpful.

3 Skin-to-skin contact within 1 hour of birth.

4 Breast feeding within 1 hour of birth

5 Your opportunity to ask questions and discuss concerns.

6 The overall experience of breastfeeding and your ability to maintain no supplements.

7 The service provided by the Lactation Consultant.

8 Staff in post partum were encouraging, supportive, and helpful

9 Your overall experience with the BFI Program at Lakeside.

10 Written discharge instructions were easy to follow

Please provide any comments on your experience with the BFI Program in this space provided:


1.1 Administration and Infrastructure

1.2 Budget 1.3 Policies and

Procedures 1.4 Staff

1.5 Marketing and

Communication Plan

1.6 Collaboration

and Partnerships 1.7 Target Group

Appendix #3

BFI

Logic Model

Program Goal: Achieving Baby Friendly Designation

Process Outcomes

1.0 Admin

Supports/Inputs/

Resources

2.0 Program

Implementation/Process

3.0 Outputs

4.0 Short-Term

Outcomes

(6 months)

5.0 Intermediate-

Term Outcomes

(1 Year)

6.0 Long-Term

Outcomes

(1.5 Years)

2.1 Implementation team established

2.2 Antenatal screening and

referral 2.3 Case Management

established 2.4 Interventions established

and implemented 2.5 Support system

established 2.6 Monitoring and tracking

of program progression 2.7 Linking referrals to

community programs

3.1 The BFI Program

is implemented

3.2 Target group is

screened and

referred

3.3 Access to

resources by key

stakeholders

established

4.1 Breast feeding policy approved and implemented

4.2 Staff education completed

4.3 Communication

plan established 4.4 Target group

receives education 4.5 Rooming in for

target group and their supports

4.6 Skin to skin

contact within ½ hour after birth

4.7 Breast feeding

within 1 hour of birth

4.8 No supplementation for all healthy babies

5.1 Exclusive breastfeeding ≥6 months to 24 months for 80% of healthy babies

5.2 Babies in the

program do not receive artificial nipple or pacifier

5.3 Restricted access

to formula in hospital

5.4 Uptake of

attendance at support groups

6.1 Key stakeholders support BFI implementation

6.2 Increased

education of target group on the benefits of BFI

6.3 Awarded Baby

friendly designation


Appendix #4

Data Collection Matrix for the Baby Friendly Initiative (BFI)

Evaluation Topic Evaluation Questions Indicators Data Sources/Tools

PROCESS

1.0 Inputs

1.1 Administration and Infrastructure

1.1.1 To what extent did the infrastructure developed meet the needs for the key program activities?

Evidence of the effect of the

infrastructure in supporting

the program

Views of the effect of

infrastructure in supporting

the program

Evidence of administrative

success/lack of success

Views of stakeholders

Document review (policies and

procedures; educational

material/manual)

Key stakeholder interviews

1.2 Budget 1.2.1 Are allotted resources sufficient to meet program goals and objectives?

Evidence of how resources

were used and

documentation on

variances

Staff satisfaction with

resources

Review of documented evidence:

budget review, annual report,

education plan

Key Stakeholder interviews



1.3 Policies and Procedures 1.3.1 What is the Policy in place and does

it integrate the 10 steps of the BFI

and Best Practice Guidelines of the

RNAO?

The BFI Policy

Evidence that the policies

and procedures were

implemented as described

Document review (program

staffing accountability;

interdisciplinary care plans; staff

rotations)


(mothers and staff)

1.3.2 Are all staff aware of the policy and

mandate and do they support and

follow it?

The BFI Policy

# of staff educated

Staff satisfaction with the

policy: views of staff

Evidence of policy being

followed

Views of the effectiveness

of the implementation

Document review

BORN Information System (BIS)

Indicator Report

Staff satisfaction survey

Staff interviews (selected)

1.4 Staff 1.4.1 Did the BFI Program staffing model meet the service needs of the program?

Evidence of number of staff

involved and the staffing

model

Views of the use and

adequacy of staffing levels

Demonstrated ability to

reach all mother/baby

dyads with interventions at

recommended times

Document review, staffing

patterns


BIS Indicator Report



1.5 Marketing and Communications plan

1.5.1 How effective was the marketing and communication plan in reaching the intended audience?

Communication plan and

Marketing plan

Views on the how the

communications plan and

marketing plan were carried

out

Documentation of feedback

received on the

communication plan

Document review

Key Stakeholder Interviews

(selected)

Physician E-mail Survey

1.6 Collaboration and partnerships

1.6.1 What types of collaborations and

partnerships were established?

Consultation plan available

Views on how the

consultation plan was

developed

List of types of

collaborations and

partnerships

Document review


(selected)

Physicians – OB/Paeditricians

Midwives

Nursing staff

Public Health LC

1.6.2 What services were provided by

the collaborations and partnerships

and what was their effect?

Service documentation

Staff satisfaction with

services provided in adjunct

to the BFI program

Target group satisfaction

with services provided

Document review


Mother satisfaction survey

BIS Indicator report



1.6.3 To what extent did was PH able to

support the mothers? Was there a

wait list for service?

Evidence of PH service

provided

Mother satisfaction with

services provided

PH views on services

provided

Document review



Key stakeholder interviews (selected)

1.7 Target group 1.7.1 To what extent did the participants

reflect the intended target group?

What were the differences

observed?

Referral patterns:

# of mothers

# of mothers participating

in the BFI program

Document review: demographics of target population, documentation of referrals

Focus group

BIS indicator report

PHU indicator report

2.0 Implementation

2.1 Implementation team established

2.1.1 What is the structure of the

implementation team and to what

extent were they able to implement

the BFI Program?

Team structure

# of staff educated

# of staff on the team

# of moms exclusively

breastfeeding

Document review

Key Stakeholder Interviews (selected)

BIS indicator report

Lakeside data

2.1.2 What factors helped or hindered the development of the implementation team?

Issue identification Key Stakeholder Interviews

(selected)



2.2 Screening and referral 2.2.1 Were the elements in the screening

tool sensitive enough to meet the

needs of the target population?

Views on eligibility for BFI Program

Evidence that the referrals completed resulted in service provided

# of Target groups screened

# of Target groups receiving services that meet their needs

Document Review (policies and

procedures)


(selected)

2.2.2 To what extent did the antenatal

screening tool identify the intended

target group?

# of mothers screened

# of mothers receiving interventions

Document review




2.3 Case Management established

2.3.1 To what extent did the care plans

describe the goals or needs of the

client?

Evidence within the care

plan that the clients’ plans

are individualized, identify

their needs, and provide a

plan for meeting the needs


services provided

Document Review-care plan and

variance documentation

BIS data

Mother satisfaction surveys


(selected)



2.4 Interventions established and implemented

2.4.1 To what extent were interventions

that were identified implemented? Evidence of the

interventions implemented

for each mother/baby dyad

and documentation of those

interventions implemented

and not implemented

Document review – care plan

variance tracking

BIS data

2.4.2 What is the physician/midwife/lactation consultant/mother satisfaction with the interventions implemented?

Views on the effect of the

intervention

Satisfaction ratings of all key

stakeholders and mothers

Physician/midwife/lactation

consultant E-mail Survey

Mother focus group


(selected)

2.5 Support System established

2.5.1 What process is established for

identifying mothers that require

support on ante-natal, postpartum,

and on discharge?

Evidence of process established for referring- care plan provides detail of support required

Document review- # of referrals

to LC via EHR report

survey

Document review-care plan


(selected)

Public Health Unit (PHU) Indicator

Report


Evaluation Topic Evaluation Questions Indicators Data Sources/Tools 2.5.2 What are the support services

utilized and what is the rate of

referral to the support service?

Documentation of support service identified

# of mothers referred

Staff satisfaction with support services

Mothers satisfaction rating with services provided

Views on services provided by support services

Document review



(selected)


PHU Indicator Report

2.6 Monitoring and tracking of program process established

2.6.1 Has the care across the continuum from antenatal to post partum to home changed as a result of this program? In what ways has the breastfeeding experience changed?

Views on effectiveness

Staff and Target group

satisfaction

Documentation or feedback

received that details any

positive or negative changes

that would be of benefit for

recommendations

Document review

Staff surveys (selected)

Target Group focus groups

Physician surveys (selected)


2.7 Linking referrals to community programs

2.8.1 What is the process in place for linking the mother with a community program? What is the success rate of service provided?

Referral process

# of mothers referred

# of mothers receiving

service

Type of service provided


community service provided

Document review

BIS data




3.0 Outputs

3.1 The BFI Program is implemented

3.1.1 What are the determining factors that indicate that the BFI Program is fully implemented?

% of exclusive breastfeeding rates

% formula supplementation rates

% of exclusive formula feeding rates

Mother satisfaction with the BFI program

Staff satisfaction with the BFI program

Key stakeholder satisfaction with the BFI program

Views on the BFI program



Key Stakeholder Interviews (selected)

Documentation


3.2 Target group screened and referred

3.2.1 How many referrals were received? How many did the program serve?

# of referrals

# of mothers participating in

the BFI program


# of referrals to Lactation

Consultant (LC) from electronic

health record (EHR)



3.3 Key stakeholders access to resources established

3.3.1 To what extent were the care plans implemented?

Care plan review for

variance reporting

Document review: careplans


# of referrals to LC from EHR

OUTCOMES

4.0 Short-term Outcomes – 6 months

4.1. BFI policy approved

and implemented 4.1.1 To what extent do the managers

support the BFI initiative? # of managers supporting

BFI vs. those that don't

Manager satisfaction with

the BFI program


(selected)

Staff satisfaction surveys

4.1.2 How effective were the BFI interventions in increasing the rate of BFI program participants?

Rate of Breastfeeding

Satisfaction of staff , target

group, and key stakeholders

with the interventions

DMS Audit




4.2 Staff education completed 4.2.1 Who received education and from whom did they receive it?

# and classification of

individuals receiving

education


individuals providing

education

Staff education records


Staff interviews (selected)

Staff focus group

4.2.2 Were the Key Stakeholders supportive of the process and support the education?

Key stakeholder feedback on

the education provided

# and classification of key

stakeholders


individuals providing

education

Key stakeholder education

records

Key stakeholder satisfaction

survey


(selected)

4.3 Communication Plan established

4.3.1 What audience did the communication plan reach and what was the response to the communication?

Communication Plan listing

target audience

Issues identified

Physician E-mail Survey

Key Stakeholder interviews (selected)

Document review



4.4 Target group receives education

4.4.1 To what extent did the Mothers feel supported and satisfied with education provided?

Mothers reported level of

satisfaction with the

education provided, broken

down into categories of

antenatal, post partum and

discharge

Increase in % of exclusive

breastfeeding rates

Mother satisfaction


4.4.2 What are the results of the mothers’ satisfaction survey on the efficacy of breast feeding education?

Mothers reported level of

satisfaction with education

provided

Increase in % of exclusive

breastfeeding rates

Documentation on care plan

variances

Staff reported level of

satisfaction on mothers’

education uptake

Document review




4.5 Rooming in for target groups and their supports

4.5.1 Did all the mother/baby dyads remain together unless medically contraindicated?

# of mother/baby dyads

# of mother/baby dyads that

remained together

Variance reporting


Document review: care plan for

variance reporting



4.6 Skin to Skin contact within ½ hour of birth

4.6.1 Did all staff receive education on the importance of immediate skin-to-skin contact?

# of staff

# of staff that received

education

Education Plan

Target Group Satisfaction


4.6.2 Was skin-to-skin contact maintained during newborn assessment and while breast feeding initated? What length of time was skin-to-skin contact maintained?



maintained skin-to-skin

contact


4.6.3 What was the mothers’ reported satisfaction rating with skin-to-skin contact?

Mother satisfaction rating Mother satisfaction survey

4.7 Breast feeding within 1 hour of birth

4.7.1 Did all staff receive education on the importance of breastfeeding within 1 hour of birth?

# of staff

# of staff educated

Education Plan includes

breastfeeding within 1 hour

of birth

Staff Satisfaction

Document review: Education plan


4.7.2 What is the mothers’ reported satisfaction rating with breast feeding within 1 hour?

Mother satisfaction rating

on breastfeeding within 1

hour of birth




4.7.3 What is the percentage of babies being breastfed within 1 hour of birth?



breastfeeding within 1 hour

of birth


4.7.4 What factors helped or hindered breast feeding within 1 hour of birth?

Care plan variance tracking

documenting barriers to

breast feeding

Staff and mother feedback


variance tracking

Document review:

documentation of feedback

4.8 No supplementation for all healthy babies

4.8.1 What is the rate of education completed for moms on hand expression or how to pump if away from the baby?



received teaching on how to

maintain breast feeding

when separated for a period

of time


4.8.2 Did all women who had difficulty

with breastfeeding receive support

from the designated specialist? If

they did not, what were the barriers

or explanations?

Evidence of the education

model

Views on the education plan

Target group satisfaction

with the support

Views of the consultant on

the referral process

Key stakeholder interviews: Consultant/Educators/staff (selected)


Document review: referral process

% of referrals to LC



4.8.3 What is the process developed for

referral to consultants?

Evidence of referral process

# of moms referred

BIS data

Document review: process

4.8.4 What is the rate of reported mothers’ satisfaction with maintaining breast feeding?

Mothers’ satisfaction rating


for requiring

supplementation

Mothers’ satisfaction survey


variance tracking

5.0 Intermediate-term Outcomes – 1 Year

5.1 Exclusive breast feeding> 6 months to 24 months for 80% of healthy babies

5.1.1 Has the working group been maintained for consistency of implementation?

BFI Program staff model and

rate of replacement of staff

Human Resources reports on staff

turnover

Staff surveys


5.1.2 What are the sustained results of the BFI Program and how are they communicated to key stakeholders?



exclusively breast feeding

Communication plan

documenting the results,

recommendations, and

communication to key

stakeholders


Document review:

communication plan feedback

5.1.2 Is all advertising material free of formula advertisements

Review of advertising

material for material

Advertising material



5.2 Babies in the program do not receive artificial nipple or pacifiers

5.2.1 Were all mothers educated on avoiding the use of artificial teats or pacifiers for breast feeding infants?



were educated on avoiding

the use of artificial teats or

pacifiers


5.3 Restricted access to formula in hospital

5.1.1 Who controls access to formula? What criteria determines need for access?

# of times formula accessed


documenting the need for

formula

% of formula

supplementation rates

Views on formula

Access Process – formula

decanted in non-labeled

container

Document Review-care plan

review for variance tracking

Document review of access policy

and Procedure


5.4 Uptake of attendance at support groups

5.4.1 What are the support groups that mothers are attending and what is the rate of attendance?

# and type of support

groups

# of mothers attending

support groups

BIS data

Document review: care plan



6.0 Long-term Outcomes – 1.5 years

6.1 Key Stakeholders support BFI implementation

6.1.1 What is the rate of satisfaction of the Key Stakeholders? What are the identified successes/areas for improvement identified in satisfaction surveys/interviews?

Rate of satisfaction of key

stakeholders

Qualitative feedback

obtained in surveys

Documentation of feedback

received

Key Stakeholder satisfaction

surveys


Document review: feedback

received

6.2 Increased education of target group on the benefits of BFI

6.2.1 What is the percentage change over time of education provided?

# of mothers exclusively

breastfeeding

# of mothers receiving

education

Views on the BFI program

breastfeeding rates @ 6

months-2 years


Satisfaction surveys: staff and

mothers


6.3 Baby friendly designation

awarded

6.3.1 How will this program maintain the BFI designation?

Program plan for staffing,

resources, education

Monthly tracking

breastfeeding rates

Document review: program plan




6.3.2 How is the need for policy updates identified?

All data compiled review

and recommendations for

program improvement as

per the BCC BFI assessment

guidelines

Policy updates incorporate

WHO updates, BCC and

RNAO best practice

guideline updates

All data

All document review


WHO documents

RNAO best practice guideline

documents

Team Ontario Baby Friendly Initiative Evaluation...

Documents

Transcript of Team Ontario Baby Friendly Initiative Evaluation...