Development of the Breastfeeding Quality Improvement in Hospitals Learning Collaborative in New York State

Abstract

Exclusive breastfeeding is a public health priority. A strong body of evidence links maternity care practices, based on the Ten Steps to Successful Breastfeeding, to increased breastfeeding initiation, duration and exclusivity. Despite having written breastfeeding policies, New York (NY) hospitals vary widely in reported maternity care practices and in prevalence rates of breastfeeding, especially exclusive breastfeeding, during the birth hospitalization. To improve hospital maternity care practices, breastfeeding support, and the percentage of infants exclusively breastfeeding, the NY State Department of Health developed the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative. The BQIH Learning Collaborative was the first to use the Institute for Health Care Improvement's Breakthrough Series methodology to specifically focus on increasing hospital breastfeeding support. The evidence-based maternity care practices from the Ten Steps to Successful Breastfeeding provided the basis for the Change Package and Data Measurement Plan. The present article describes the development of the BQIH Learning Collaborative. The engagement of breastfeeding experts, partners, and stakeholders in refining the Learning Collaborative design and content, in defining the strategies and interventions (Change Package) that drive hospital systems change, and in developing the Data Measurement Plan to assess progress in meeting the Learning Collaborative goals and hospital aims is illustrated. The BQIH Learning Collaborative is a model program that was implemented in a group of NY hospitals with plans to spread to additional hospitals in NY and across the country.

Introduction

Breastfeeding provides many health and economic benefits to mothers, infants, and the public.^1,2 Hospital breastfeeding policies and maternity care and infant nutrition practices have a profound effect on the breastfeeding success of mothers and infants in the hospital and during the first 6 months of life.^3–6 The World Health Organization identified a set of evidence-based maternity care practices, the Ten Steps to Successful Breastfeeding, that increase breastfeeding initiation, exclusivity, and duration.³ The importance of exclusive breastfeeding is increasingly recognized.¹ Exclusive breastfeeding is now included in the Joint Commission's Perinatal Care Core Measures,⁷ and the Healthy People objectives have increased the targets for exclusive breastfeeding at 3 months from 40% in 2010 to 46.2% in 2020.^8,9

In 2004, the New York (NY) State Department of Health (NYSDOH) incorporated many of the Ten Steps to Successful Breastfeeding into the NY Hospital Codes, Rules and Regulations (10NYCRR§ 405.21).^10–12 Despite state regulations, a 2007 survey of NY hospitals reported incomplete implementation of specific maternity care practices, with a range from 48% to 84%.¹³ In 2008, the prevalence of exclusive breastfeeding during the birth hospitalization varied widely, from 2% to 98% of infants, across NY hospitals (Bureau of Biometrics, NYSDOH, unpublished electronic birth certificate data). In a survey of NY mothers, 37% reported that infant formula was given to their breastfed infant during the first 2 days of life, typically during the birth hospitalization.¹⁴

To increase rates of exclusive breastfeeding during the birth hospitalization and beyond, the NYSDOH designed an 18-month Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative. The present article describes the development of the Collaborative, including the structure, tools, and measures. It serves as a “blueprint”¹⁵ for future Collaboratives in addressing improvement in breastfeeding metrics through institution of evidence-based maternity care practices in hospitals.

Materials and Methods

BQIH Learning Collaborative in NY State

The Institute for Healthcare Improvement's (IHI's) Breakthrough Series Learning Collaborative Model¹⁶ was adapted for this project. The BQIH Collaborative was a short-term learning system that brought NY hospitals together to apply quality improvement tools and techniques to change care systems and close the gap between current and recommended hospital maternity care practices that impact breastfeeding. During the BQIH development phase, which began a year before implementation, the Collaborative structure, time frame, and documents were created or adapted. These included the Change Package (a set of recommended concepts for practice changes to be tested and implemented) and the Data Measurement Plan (a suite of key measures used to track improvements over time).

Components of the Collaborative included the Pre-work period, Learning Sessions, and Action Periods. During the Pre-work period, participating hospitals established quality improvement teams, which included the Director of Women's Services or Nurse Manager for Maternity Services, physician leads from both the Departments of Pediatrics and Obstetrics, the Lactation Consultant, and a senior hospital administrator. These teams assessed their baseline hospital maternity care practices and breastfeeding metrics (i.e., percentage of infants receiving any breastmilk, percentage receiving exclusively breastmilk, and percentage of breastfed infants being supplemented with formula). The Learning Sessions were periodic meetings for all Collaborative hospitals to learn skills needed to support and sustain improvement. Each Learning Session was followed by an Action Period. Content for the Pre-work period, Learning Sessions, and Action Periods was developed from evidence-based literature, quality improvement methodology, expert faculty recommendations, and the learning needs of the hospitals.

Identification of eligible NY hospitals

The BQIH Learning Collaborative was limited to NY hospitals that provided maternity care services (n=140). Hospitals located in NY City were excluded (n=40) because the NY City Department of Health and Mental Hygiene was conducting a separate, but complementary, initiative with NY City hospitals to improve breastfeeding metrics. To maximize potential impact and reach, hospitals with fewer than 400 births annually were excluded (n=25). The breastfeeding metrics of the remaining 75 NY hospitals (n=140−[40+25]) were evaluated. Hospitals were categorized as low-, high-, or medium-performing hospitals based on their breastfeeding metrics.¹⁷ Twenty-three hospitals were categorized as low performing, and five were categorized as high performing. These 28 hospitals were invited to apply to participate; 17 applied, indicating they would attend all Learning Sessions, participate in monthly group and individual calls, and submit data monthly.¹⁷ Each participating hospital was reimbursed up to $5,000 ($1,000 after each of the five Learning Sessions) to partially compensate for staff time and travel expenses.

Infrastructure and partnerships

The NYSDOH established a Project Leadership Team that included a project director, coordinator, and experts in breastfeeding medicine, quality improvement, systems change, and data analysis and evaluation. The NYSDOH partnered with the National Initiative for Children's Health Care Quality (NICHQ), leaders in quality improvement for infant and child health, to provide expert consultation on quality improvement and co-manage the Collaborative. In addition, the NY Breastfeeding Partnership Team, which included key stakeholders and organizations with expertise in breastfeeding medicine, public health, hospital systems, and quality improvement, was convened to review, refine, and guide the Collaborative design and content, monitor progress and results, and support the implementation and dissemination of recommended practices across all NY hospitals providing maternity care services.

Model for improvement

The Model for Improvement, developed by the Associates in Process Improvement,¹⁸ was the method used to test and implement changes in hospital processes and systems. The model included two components: one was a series of questions to define the desired changes, and the second was a method for implementing the changes. The three specific questions were: (1) “What are we trying to accomplish?”; (2) “How will we know that a change is an improvement?”; and (3) “What changes can we make that will result in improvement?” The second component was the Plan-Do-Study-Act cycle, a method for conducting rapid, small-scale tests of change to implement the desired changes in the system. The following Collaborative documents were developed to address the three questions of the Model for Improvement.

Aim Statement

Evidence from the literature regarding methods and strategies for improving exclusive breastfeeding³ was used in conjunction with expert recommendations^12,19–21 to establish the overall aim of the project. The Aim Statement included time-sensitive parameters for achieving the expected results, numerical measures for goals, and the specific patient population to be affected.

Change Package

To identify key change concepts or maternity care practices shown to influence breastfeeding success, specifically, exclusive breastfeeding during the birth hospitalization, evidence reviews, expert recommendations, and the literature were evaluated.^12,19–21 Change concepts mirrored the Ten Steps to Successful Breastfeeding and were informed by accepted standards of care.^19,21,22 The literature suggested importance ranking and dose–response information for the change concepts.^4,5,23 All potential strategies to implement the change concepts were reviewed for pertinence, achievability, and redundancy and were codified in the Change Package by Department staff, breastfeeding experts, and NICHQ. Developing the Change Package was an iterative process over 3–4 months, with a final review conducted by the NY Breastfeeding Partnership Team.

Data Measurement Plan

A suite of process and outcome measures were designed to measure the degree of implementation of the Ten Steps to Successful Breastfeeding as codified in the Change Package. These measures, developed by Department staff, breastfeeding experts, and NICHQ, were intended to reflect whether the changes hospitals make actually lead to improvement.¹⁶ Specific measure definitions and goals were based on public health recommendations,^8,24 if available and, if not, from the published literature or benchmarks defined in a national survey.¹³ The Data Measurement Plan was reviewed by external experts and the NY Breastfeeding Partnership Team, for appropriateness, sensitivity to expected changes, clarity of definitions, and ease of data collection.

The Data Measurement Plan informed the development of data collection tools. A data abstraction tool was developed by Department staff to assist local data collection and reporting, recognizing that many hospitals did not have the capability of collecting this data electronically. The extranet, a secure, Web-based application hosted by IHI, was used for data submission and reporting by all hospitals.

Evaluation plan

Hospital team performance and satisfaction with the BQIH were assessed during Learning Sessions, Action Period calls, and monthly data submission. In addition, changes over time in maternity care practices, staff training, and breastfeeding metrics were included in the analysis plan.

Results

BQIH Learning Collaborative in NY State

Twelve hospitals were selected to participate: 10 low-performing hospitals (the target of the intervention) and two high-performing hospitals (to serve as “model” hospitals).¹⁷ All 12 hospitals fully participated in all components of the study, submitted all data, and completed the study.

The IHI's Breakthrough Series methodology was modified to be responsive to NY's needs (i.e., focus on low-performing hospitals). Modifications included a longer time period (i.e., 18 months), additional, individual technical assistance, and the engagement of hospital leadership. The BQIH Collaborative included a Pre-work period, followed by five Learning Sessions, one every 4 months. The in-person Learning Sessions were each 8 hours, and the Virtual Learning Sessions were each 3 hours in length. Between each Learning Session, 1-hour Action Period Webinars were held each month; they included expert faculty and teams from all 12 hospitals. Individual, monthly technical assistance calls were also conducted by a quality improvement advisor with each hospital team to review progress toward project goals and to address hospital-specific opportunities and challenges.

The Pre-work period began with a kick-off Webinar that introduced the Pre-work package, which included a hospital practice assessment survey, the Change Package, the Data Measurement Plan, and directions for collecting and reporting baseline and monthly data. The five subsequent Learning Sessions contained core BQIH Collaborative didactic content and clinical presentations. The Collaborative time frame and curriculum content are listed in Table 1. The Action Period interactive Webinars were designed to review hospital aggregate data and to share achievements and barriers experienced during testing and implementation of hospital system changes. The specific changes chosen by teams to be tested during the Action Periods were selected from the change package in real time. This flexibility was crucial because individual assessments by participating teams determined the appropriateness as well as potential success of changes to be tested and/or implemented in their hospital system. Information gathered from the first group of hospitals to participate in the BQIH would assess whether the sequence of system changes impacted change in practices and/or breastfeeding metrics. Depending on the findings, subsequent BQIH Learning Collaboratives could be more prescriptive.

Table 1.

Design and Timeline for the New York State Department of Health's Breastfeeding Quality Improvement in Hospitals Learning Collaborative

Time (months)	Event	Mode	Length (hours)	Curriculum content
1	Kick-Off Meeting	Virtual	1	• Project overview and logistics
				• Aim Statement development
				• Baseline data collection and submission
				• Storyboard development
2	Learning Session-1	In-person	8	• Overview baseline data
				• Model for Improvement
				• Best practice changes, tests of change
				• Effective teamwork
				Clinical presentation: “Translating Evidence to Practice”
3	Action Periods	Virtual	1	• Hospital progress reports, sharing successes and challenges, planning next tests of change
4			1
5			1
6	Learning Session-2	Virtual	3	• BQIH results to date: review of project progress toward Aim Statement
				• Accelerating improvement
				• Create PDSA cycle for Action Period 2
				• Hospital report out PDSA
				Clinical presentation: “Breastfeeding on Demand”
7	Action Periods	Virtual	1	• Hospital progress reports, sharing successes and challenges, planning next tests of change
8			1
9			1
10	Learning Session-3	In-person	6	• BQIH results to date: aggregate data (all hospitals)
				• Hospital report out
				• Role of leadership in success
				• Change Package exercise
11	Action Periods	Virtual	1	• Hospital progress reports, sharing successes and challenges, planning next tests of change
12			1
13			1
14	Learning Session-4	Virtual	3	• BQIH results to date: aggregate data (all hospitals)
				• Using data to drive change
				• Sustaining change: how to hardwire change
				• PDSA planning
				Clinical presentation: “Breastfeeding Need of the Late Preterm Infant”
15	Action Periods	Virtual	1	• Hospital progress reports, sharing successes and challenges, planning next tests of change
16			1
17			1
18	Learning Session-5	In-person	8	• BQIH aggregate data review (all hospitals)
				• Selected team presentations
				• Baby Friendly Hospital Initiative presentation
				• Quality initiative topic: spreading change from BQIH to other NYS hospitals
				• Celebrating successes

BQIH, Breastfeeding Quality Improvment in Hospitals; NYS, New York State; PDSA, Plan-Do-Study-Act.

Infrastructure and partnerships

The NYSDOH had identified outside expertise in breastfeeding medicine, which, combined with previous experience partnering with NICHQ advisors and staff to implement quality improvement Learning Collaboratives, allowed for quick initiation of early phases of the BQIH Collaborative.

The NYSDOH, in its leadership role as convener and facilitator, engaged strategic public and private partners to participate on the NY Breastfeeding Partnership Team. They met biannually and included representatives from professional medical societies, NY hospital associations, the NY Statewide Breastfeeding Coalition, the NY City Department of Health and Mental Hygiene, and NYSDOH, including the Office of Public Health (Divisions of Chronic Disease Prevention, Family Health, and Nutrition) and the Office of Health Systems Management. The NYSDOH also engaged individual hospital leadership, which was crucial to the initiation and success of this project. It was important to recognize that the Department's regulatory authority could potentially interfere with each hospital's transparency in participation and data reporting. Clearly defining the Department's nonregulatory role in health promotion and improvement enhanced the ability to engage and build trust with hospitals.

Model for improvement

Aim Statement

The aim of this Collaborative was to increase breastfeeding, especially exclusive breastfeeding, during the birth hospitalization, by improving hospital breastfeeding policies and maternity care practices to be consistent with NY hospital regulations and laws and with the Ten Steps to Successful Breastfeeding. Specific goals included (1) to increase the percentage of infants fed any breastmilk to 82%, (2) to increase the percentage of infants exclusively fed breastmilk to 62%, and (3) to decrease the percentage of breastfed infants who were fed formula to no more than 18%.

Change Package

The Change Package (Table 2) was designed to serve as a “menu” from which teams selected changes and supporting strategies to achieve the project aim. The change package listed 12 change concepts, based on the Ten Steps to Successful Breastfeeding. Each change concept was associated with a list of three to eight evidence-based strategies to achieve the desired system changes. All strategies supported achievement of the associated change, and participating hospitals could choose to test one or more strategies depending on identified needs and capabilities.

Table 2.

New York State Department of Health Breastfeeding Quality Improvement in Hospitals Learning Collaborative Change Package

Change concept (Step) ^3,22,25	Improvement strategy
Help mothers initiate breastfeeding within 1 hour of birth (vaginal delivery) or 2 hours of birth (cesarean section) (4)^3–5,10,21	1. Document infant feeding decision in the medical record upon admission.
	2. Initiate skin-to-skin contact. All infants should be placed naked, prone against their mother's bare chest, and remain there uninterrupted for a minimum of 30–60 minutes, after birth.
	3. Delay routine procedures including foot printing, weighing/measuring, bathing, eye prophylaxis, and needle sticks (including vitamin K) until infant has breastfed. (Note NYS regulation requires vitamin K administration by the 1-hour mark.)
	4. Encourage mothers to breastfeed for their infant's first feeding after birth.
	5. If breastfeeding is delayed due to medical condition(s) of mother and/or infant, place infant skin-to-skin and allow infant to approach the breast as soon as possible after mother and infant are stable.
Provide no supplementation (formula, glucose water, or plain water) to breastfed infants (6)^{3–5,10,21,26}	1. Place a sign in infant's bassinet stating that the infant is breastfeeding and that no bottle feeding of any type should be offered.
	2. Provide no supplemental water, glucose, or formula to breastfeeding infants unless specified by a written physician order for a clinical condition or by the mother's documented and informed request.
	3. Prior to nonmedically indicated supplementation of breastfed infants (i.e., mother's request), mothers are informed of the risks of supplementation to the establishment and success of breastfeeding. The mother's request and discussion of the risks are documented in the medical record.
	4. Utilize an alternative feeding method such as a cup (recommended), dropper, or syringe to maintain mother–infant breastfeeding skills when supplementation is medically indicated.
	5. Do NOT place bottles in a breastfeeding infant's bassinet.
	6. Document infant feeding in the medical record each shift.
	7. Institute inventory controls for formula similar to other foods, medications, and/or supplies (e.g., include formula in automated dispensing and distribution systems).
Encourage breastfeeding on demand (8)^3,4,10,26	1. Educate mothers on the “supply and demand” principle of milk production, emphasizing the importance of exclusive breastfeeding to establish and maintain the milk supply.
	2. Allow frequency and duration of breastfeedings to be infant-led. Non-timed feedings and cue-based offerings are the basis of mother–infant care. Tell mothers to expect eight or more feedings of breastmilk in 24 hours of no particular pattern or frequency.
	3. Educate mothers during postpartum periods regarding typical infant feeding cues and readiness to feed.
	4. Educate staff about typical infant feeding cues so that staff are able to help mothers respond to those cues.
	5. Encourage mothers to monitor personal signs and infant signs of adequate/inadequate intake and output.
Practice rooming-in (minimum of 18 hours a day) (7) ^3–5,10,21	1. Practice rooming-in throughout the facility unless medically contraindicated or the facility does not have sufficient capacity to accommodate rooming-in requests.
	2. Do NOT routinely separate healthy mothers and infants during the hospital stay.
	3. Care for infant at mother's bedside. Examine the routine procedures that “require” infant to be taken to the nursery. Determine which procedures could be done in mother's room to offer opportunities for more education during assessment.
	4. Use portable scales, bath equipment, etc., in order to conduct procedures at mother's bedside.
	5. Provide information about the benefits of rooming-in to mothers who request separation from their infant.
	6. If a breastfeeding mother requests that her infant stay in the nursery, take the infant to the mother to be fed whenever the infant displays hunger cues.
	7. Feed an infant in a manner that is consistent with preserving breastfeeding (i.e., cup, dropper, or syringe) if a mother is unable or refuses to feed her infant during the night. Document in the medical record.
	8. Prioritize skin-to-skin contact and breastfeeding over other routine events such as infant bathing, pictures, and visitors during an infant's first day of life.
Show mothers how to breastfeed. Provide instruction in…(5) ^3,10,26	1. Document breastfeeding instruction and assessment each shift.
	2. Instruct mothers about the benefits of breastfeeding, importance of colostrum, importance of exclusive breastfeeding, basics of breastfeeding management, possible effect of analgesia/anesthesia on infant behavior, and rationale for early skin-to-skin contact, rooming-in, and feeding on cue. Anticipate concerns about adequacy of milk supply and infant satiety.
	3. Ensure that at least one staff member is available at all times who is qualified to assist and encourage mothers with breastfeeding. (Qualifications include IBCLC, CLC, or, at minimum, the Ten Steps to Successful Breastfeeding 18-hour course or equivalent training.)
	4. Instruct mothers about specific breastfeeding skill and ensure that they are able to do the following:
	a. Position the infant correctly so that infant can latch at the breast with no pain during feeding.
	b. State when the infant is swallowing milk.
	c. State that the infant should receive eight or more feedings of breastmilk in 24 hours, and breastfeed until satisfied.
	d. State the age-appropriate elimination patterns (i.e., at least six urinations and three to four stools) for Day 4 of life.
	e. List indications for calling a physician.
	f. Manually express milk from breasts.
	5. Ensure that staff provide consistent, positive messages about breastfeeding to all mothers who deliver within the hospital.
	6. Provide instruction using a combination of techniques including, but not limited to, 1:1 teaching, group classes, pamphlets, and videotaped instruction. Instructional materials should reflect the cultural background, education, age, and language of the patient population.
	7. Instruct mothers about method of hand expression of breastmilk and use of electric pump. Encourage mothers to maintain lactation if separated from their infant so that breastmilk can be made available to infant. Mothers should be educated about sanitary procedures for collecting and storing their milk.
	8. Arrange for trained peer counselors (i.e., WIC) to make rounds and educate breastfeeding mothers.
Assess breastfeeding regularly (5) ^3,10,26	1. Document breastfeeding instruction and assessment each shift.
	2. Ensure that a trained physician, nurse, or lactation specialist performs a functional assessment of the infant at the breast within 8 hours (or sooner) of birth by utilizing an assessment tool such as IBFAT, FAIB, or LATCH and at least once every 8 hours while infant and mother remain in the hospital.
	3. Request a lactation consultatation when an assessment identifies a dysfunction or the infant displays signs of inadequate intake.
Restrict use of pacifiers (9)^3–5,26	1. Do not offer healthy breastfed infants pacifiers or artificial nipples. (There may be a role for pacifier use in the preterm or ill infant who is not able to suckle at the breast).
	2. Encourage mothers to hold and breastfeed infants during, or immediately following, routine painful procedures such as heel sticks and intramuscular injections.
	3. Educate staff about soothing techniques such as skin-to-skin, breastfeeding, walking, and rocking to use with their infant.
	4. Implement skin-to-skin and rooming-in protocols to promote infant soothing opportunities.
Provide postdischarge breastfeeding support (10)^{3–5,10,21,26}	1. Assess available community breastfeeding support resources and maintain a current list of community lactation resources for specific referrals of breastfeeding mothers.
	2. Provide breastfeeding mothers with telephone numbers of lactation consultants and/or community resource for breastfeeding assistance.
	3. Refer breastfeeding mothers to a breastfeeding support group.
Restrict distribution of formula^26–31	1. Do not provide mothers with free formula samples.
Provide commercial-free educational materials on discharge^26–31	2. Do not provide mothers with items bearing formula company names or logos, coupons for formula, or other inducements for supplementing breastmilk.
	3. Work with marketing to develop educational information about infant feeding and/or infant care that is free of commercial messages or logos. Develop “formula-free” discharge gift pack free for all families.
	4. Ensure that all education media are free of commercial messages and logos used to promote formula and artificial feeding.
	5. Purchase infant formula and feeding devices in the same manner as other food and supplies and incorporate purchases into insurance reimbursement contracts.
	6. Document the actual amount of formula used (versus what is stocked) and its fair market price as a basis for future consideration of purchasing formula.
	7. Institute inventory controls for formula issuance similar to other foods, medications, or supplies.
Ensure adequate training of healthcare staff (2)^3,10,26	1. Require that all staff with primary responsibility for the care of breastfeeding mothers and infants complete the Ten Steps to Successful Breastfeeding 18-hour interdisciplinary breastfeeding management course for the United States or equivalent and a post-test verification.
Prepare new staff	2. Require that all staff with primary responsibility for the care of breastfeeding mothers and infants annually complete 5 or more hours of evidence-based updates to knowledge and skills for the support, promotion, and protection of breastfeeding; methods may include in-service education, certification courses, skills labs, conferences, Web-based training, journal articles, etc.
Provide continuing education	3. Provide a 1-hour orientation for all support staff to enlist them in supporting and promoting hospital breastfeeding policies and practices.
Assess competency of staff	4. Consider low-cost training modalities such as the following: integrating breastfeeding education into existing staff meetings, sending key staff to “train the trainer” programs and then offering in-house training, providing self-study training modules acquired from outside vendors or constructed from recent journal articles, and providing Web-based training.
Communicate breastfeeding policy with staff (1)^3,10,26	1. Designate at least one person who is thoroughly trained in breastfeeding physiology and management to be responsible for ensuring the implementation of an effective breastfeeding program.
	2. Create an interdisciplinary, culturally appropriate team composed of hospital staff whose goal is to reduce institutional barriers to breastfeeding.
	3. The facility will have a detailed breastfeeding policy that is inclusive of the Ten Steps to Successful Breastfeeding and NYS laws and regulations and is routinely communicated to all healthcare staff.
	4. Use a self-appraisal tool to examine how the current practices differ from those expected by the Ten Steps.
	5. All hospital departments serving mothers, infants, and/or children comply with the facility's breastfeeding policy.
	6. Institute methods to verify that maternity care practices are consistent with hospital breastfeeding policy.
Inform all pregnant women about the benefits of breastfeeding (3)^3,10	1. Position education resources such as posters, videos, peer counselors, and educators to present concise messages about infant feeding in obstetric care waiting rooms, ultrasonography, laboratories, and other locations where pregnant women visit within the hospital.
	2. Ensure that nurses, certified nurse-midwives, and physicians discuss current recommendations with new mothers regarding specific medical risks of artificial infant milk for infants.
	3. Weave infant feeding education into regular childbirth classes if provided, rather than offering an optional class at the end of the series.
	4. Invite other community breastfeeding stakeholders (e.g., La Leche League, WIC, lactation consultants) to provide education on-site.
	5. Utilize NYCDHMH, NYSDOH, or NYS WIC materials to distribute through affiliated prenatal care providers.

All change concepts based on The Ten Steps to Successful Breastfeeding. The number of the Step is in parentheses after each concept.

CLC, Certified Lactation Consultant; FAIB, Functional Assessment of the Infant at the Breast; IBCLC, International Board Certified Lactation Consultant; IBFAT, Infant Breastfeeding Assessment Tool; NYCDHMH, New York City Department of Health and Mental Hygiene; NYS, New York State; NYSDOH, New York State Department of Health; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.

Data Measurement Plan

The Data Measurement Plan contained a total of 17 measures. For each measure, the plan provided the measure name, definition, numerator and denominator, data source (medical record or hospital log), and reporting frequency. The primary denominator for measures was the population of focus, or all healthy, live-born infants, excluding infants admitted to a neonatal intensive care unit and/or transferred in or out of the hospital. For some measures, the denominator was limited to breastfeeding infants or mothers, as appropriate. For the measure of initiation of breastfeeding, the denominator was stratified by birth method (vaginal or cesarean section). A sample of measures is shown in Table 3, demonstrating the link between the measures and the Ten Steps to Successful Breastfeeding. The complete Data Measurement Plan is available on the NYSDOH Web site.³²

Table 3.

New York State Breastfeeding Quality Improvement in Hospitals Data Measurement Plan Linkage of Measures to the Ten Steps to Successful Breastfeeding

Ten Steps ^a	Measure	Goal (%)
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.	Percentage of breastfeeding policy components specified by NYS Hospital Rules and Regulations (10 NYCRR § 405.21) included in the hospitals breastfeeding policy	100
2. Train all healthcare staff in skills necessary to implement this policy.	Percentage of staff assigned to mother–infant care who received training on breastfeeding and lactation support	>90
3. Inform all pregnant women about the benefits and management of breastfeeding.	Percentage of mothers with feeding decision documented in the medical record	>90
4. Help mothers initiate breastfeeding within the first half hour of birth.	Among vaginal births, percentage of infants fed breastmilk within 1 hour of birth	>90
	Among cesarean section births, percentage of infants fed breastmilk within 2 hours of birth	>90
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.	Percentage of mothers who received breastfeeding instruction	>90
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.	Percentage of infants:
	1. Fed only breastmilk	>62
	2. Fed only formula	<25
	3. Fed both breastmilk and formula	<18
	4. Fed neither breastmilk nor formula	NA
7. Practice rooming-in, allow mothers and infants to remain together—24 hours a day.	Percentage of breastfeeding infants who roomed-in with mother >18 hours/day (>6 hours per 8-hour shift)	>90
8. Encourage breastfeeding on demand.	Percentage of breastfeeding infants who received 8 or more feedings every 24 hours	>90
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.	Percentage of breastfeeding infants given a pacifier	<9
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.	Percentage of breastfeeding mothers provided breastfeeding support upon discharge	>90

Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF statement published by the World Health Organization Ten Steps to Successful Breastfeeding.¹²

NA, not applicable; NYS, New York State.

During implementation, hospital teams abstracted data each month for a random sample of healthy infants and posted the data to the secure extranet housed on the IHI Web site. Aggregate data, in the form of monthly run charts, were available to all teams and to BQIH Collaborative staff at NYSDOH and NICHQ.

Discussion

This article describes the development of the NY BQIH Learning Collaborative, the first state health department–sponsored Collaborative using the IHI methodology to have a primary focus on increasing exclusive breastfeeding during the birth hospitalization. Quality improvement was recommended more than 15 years ago, as a strategy to improve hospital maternity policies and practices related to increasing breastfeeding.³³ Recently, Bartick et al.³⁴ highlighted the role of statewide learning collaboratives led by state health departments as a primary strategy to achieve improvements in the quality of breastfeeding care. Although several other states have worked to increase adoption of the evidence-based maternity care practices with programs such as California Birth and Beyond,³⁵ Texas Ten Step,³⁶ and Colorado Can Do 5,³⁷ none of these involved the intensive model used by the NY BQIH Collaborative. In Vermont, a quality improvement collaborative in hospitals involved newborn preventive services including breastfeeding as a measure, but it was not the primary focus of the initiative.³⁸

Strengths of the BQIH Collaborative include that it was adapted from the IHI's Breakthrough Series Collaborative Model,¹⁸ an evidence-based, quality improvement methodology that incorporated the fundamental principles of quality improvement and system redesign into a structured learning system.^39–41 The BQIH Collaborative modified the IHI model to target lower performing hospitals by increasing the length of the collaborative and providing additional, individualized coaching.

Limitations of this Collaborative model include the resources required to develop and implement the BQIH; approximately $850,000 in grant funding, plus in-kind NYSDOH staff time, was committed to this project over 2 years. Now that the methodology and tools have been created, however, further implementation of the BQIH with subsequent cohorts would be expected to cost less. Nonetheless, sustainability always remains a concern. The existing infrastructure and networks resulting from this Collaborative, combined with NY's statutes and regulations requiring hospitals to support breastfeeding mothers and to publicly report hospital-specific breastfeeding performance metrics, may help sustain these efforts.¹¹ The recent public attention to the importance of breastfeeding and the benefits of Baby Friendly Hospitals may encourage hospitals to improve their breastfeeding support. In addition, the descriptions of the Collaborative methodology, time frame, curriculum content, engagement of expert partners and stakeholders, and the development of the BQIH Aim, Change Package, and Data Measurement Plan, are now available to other hospitals across NY and the nation. These tools can be adapted by individual hospitals, other states, and organizations and be further refined based on results of implementation.

Hospital maternity care practices impact breastfeeding initiation, exclusivity, and duration. The goal in NY is to make exclusive breastfeeding the norm by ensuring new mothers receive optimal breastfeeding support from prenatal, postpartum, and pediatric healthcare providers and staff.¹¹ The quality of breastfeeding support depends on the performance capability of healthcare systems. Policy alone does not achieve best practice. This Collaborative was designed to develop hospitals' capacities to improve their maternity care delivery systems to positively impact breastfeeding support.

The implementation of the BQIH has been described by Hisgen et al.¹⁷ Evaluations of the impact of the BQIH on hospital policies, practices, and breastfeeding metrics are in process. Further studies are needed to determine the impact of the BQIH on breastfeeding exclusivity and duration after the hospital stay and to evaluate the costs and benefits. These findings will help guide subsequent quality improvement efforts in NY and other states.

Footnotes

Acknowledgments

Thank you to Cynthia R. Howard, MD, MPH, Associate Professor in the Department of Pediatrics at the University of Rochester School of Medicine and Dentistry and Pediatric Director of the Mother-Baby unit at Rochester General Hospital, Charles J. Homer, MD, MPH, President and CEO, and Patricia Heinrich, RN, MSN, Improvement Advisor, National Initiative for Children's Healthcare Quality, for their contributions to the development of the BQIH Learning Collaborative. This work was supported in part by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, American Recovery and Reinvestment Act of 2009, Communities Putting Prevention to Work State Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control, and Behavioral Risk Factor Surveillance System DP09-901/3U58DP001963-01S2, Cooperative Agreement 5U58/DP001414-03 from the Centers for Disease Control and Prevention, and the New York State Department of Health.

Disclosure Statement

No competing financial interests exist.

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