Crafting an Evidence-Based,Accreditation Council of Graduate Medical Education-Compliant Lactation Policy for Residents and Fellows

Abstract

Background:

New Accreditation Council of Graduate Medical Education (ACGME) requirements mandate lactation accommodations for resident physicians and fellows. However, to date, few training programs have developed and reported robust lactation support programs or policies.

Objective:

The authors aimed to develop an evidence-based, ACGME-compliant policy to optimize lactation support for residents and fellows at their institution.

Methods:

Six Sigma process improvement methodology was utilized to structure this 2018–2019 project. Qualitative methods included stakeholder analysis, feedback sessions, formal needs assessments, and a thorough review of breastfeeding law, societal guidelines, and best practices. Quantitative methods included use of a standardized grading tool for lactation facilities. Quality assurance efforts are ongoing to ensure successful implementation of the developed policy.

Results:

The authors present a framework for improving lactation support for residents and fellows and share an institutional policy suitable for implementation by other graduate medical education departments.

Conclusions:

To ensure compliance with ACGME requirements and address breastfeeding challenges faced by medical trainees, it is crucial that U.S. residencies and fellowships implement lactation policies to support trainees. The authors welcome the modification and utilization of the evidence-based, ACGME-compliant policy reported herein.

Introduction

In a climate of unprecedented rates of physician burnout, there is growing interest in cultivating resiliency and instilling healthy self-care habits among trainees. Recent additions to the Accreditation Council of Graduate Medical Education (ACGME) Common Program Requirements focus on promoting wellness of resident physicians and fellows. Among these is a new core requirement, effective July 1, 2019 and subject to citation July 1, 2020, that programs “ensure healthy and safe learning and working environments that promote resident/fellow well-being and provide for…clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.”^1,2

Breastfeeding is the biologic norm, and women and infants who do not breastfeed are at increased risk of multiple adverse health outcomes.³ Support for breastfeeding has been identified by the Surgeon General as a national health priority,⁴ and the Healthy People 2020 Initiative includes goals for increasing breastfeeding rates and proportions of employers offering worksite lactation support.⁵ United States breastfeeding rates fall short of national and global recommendations, and women physicians have been identified as a particularly high-risk population.⁶ Therefore, training program support of lactating trainees serves not only to promote wellness but also manifests public health benefits.

To date, few training programs have reported development of lactation support programs or policies in response to the new ACGME requirements. Several departmental policies have been described,^7–9 but to our knowledge, no institution-wide policies crafted specifically for compliance with these requirements have been developed and published. Creating shared practices to assist with compliance can mitigate significant time and effort on the part of each individual institution, minimize variability between programs, and ensure equity. The specific aims of this report are the following: (1) to describe a framework for improving lactation support for residents and fellows and (2) to share an evidence-based lactation policy suitable for wide implementation by graduate medical education (GME) departments.

Materials and Methods

Following the publication of the revised ACGME Common Program Requirements, a resident and program director approached the institutional GME office to discuss the new requirement for lactation accommodations and offer assistance in executing a process improvement project to optimize support for breastfeeding trainees.

Context

Vidant Medical Center (VMC) is the flagship hospital of a regional hospital health system, which serves over 1.4 million people across 29 counties in eastern North Carolina. This tertiary care facility has over 900 beds and employs more than 7,000 individuals. Our hospital boasts a Baby-Friendly^® designation and offers multiple breastfeeding support resources for patients, which are also available to employees. VMC is also the primary teaching hospital for the Brody School of Medicine (BSOM) at East Carolina University. VMC and BSOM jointly offer 10 ACGME-accredited residencies, 3 combined residency programs, and 18 ACGME-accredited fellowships. There are 392 total trainees in these programs, of which 198 are female. All inpatient rotations occur within the Vidant health system, while outpatient clinics are largely housed in BSOM facilities.

Interventions

A project plan was structured utilizing the Six Sigma Define Measure Analyze Improve Control (DMAIC) process improvement methodology.¹⁰ A key stakeholder team was assembled, consisting of GME leadership, hospital administration, an international board-certified lactation consultant (IBCLC) from our women and children's hospital, a resident representative, and a program director representative. At the first stakeholder meeting, the following plan of action was agreed upon: (1) define key terms in the ACGME requirement, (2) measure the needs of lactating trainees, (3) analyze our institution's current resources for lactating women and identify areas for improvement, (4) improve lactation support at our institution via implementation of an institutional policy and facility upgrades, and (5) control for process improvement by developing plans for evaluating policy utilization and potential for optimization. This process improvement project was executed in 2018–2019.

Measures and analysis

Data sources for this process improvement project included a comprehensive review of national and state breastfeeding laws, societal guidelines, best practices for lactation support programs and lactation facilities, and published lactation policies from other institutions. A literature review was performed to understand the scope of the issue and put into context the local problem of lactation support for trainees. Feedback was elicited from a focus group of 10 current and recently graduated trainees at our institution to collect comments about personal experience navigating lactation support resources during residency or fellowship. A walk-through was performed with hospital administrative leaders and materials management staff to assess the physical amenities of existing lactation rooms and potential spaces for additional rooms, and an evidence-based standardized grading tool was developed to quantitatively assess compliance with ACGME standards and established best practices. The structure of the ensuing report adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines.¹¹

Results

Key results of this process improvement project are highlighted in Table 1 and detailed below.

Table 1.

Key Results of the 2018–2019 Process Improvement Project to Optimize Support for Breastfeeding Trainees at Vidant Medical Center/Brody School of Medicine

Defining key terms in the ACGME requirement.

• Stakeholders agreed on definitions of key terms after reviewing standard terminology used in federal and state laws and guidelines about breastfeeding.

• Definitions were published in the institutional policy (Supplementary Data).

Measuring the needs of lactating trainees.

• A literature review was performed to understand the general needs of breastfeeding trainees in the nation. Many trainees report challenges related to time, space, and workplace culture.

• A resident and fellow advisory committee was assembled to measure the specific needs of breastfeeding trainees at our institution.

○ Results of focus group sessions are highlighted in Table 2.

○ Specific improvements needed to optimize institutional lactation support for trainees were cataloged in a formal needs assessment document.

Analyzing our institution's current resources for lactating women and identifying areas for improvement.

• The stakeholder team compiled a list of current lactation resources.

○ Focus group sessions revealed that many trainees are unaware of these resources.

• The general employee lactation policy was compared to the ACGME requirement.

○ The current policy lacks language about refrigeration and proximity to patient care.

• A walk-though was conducted to assess current lactation rooms and identify potential spaces for additional rooms.

○ Walking time was measured to determine proximity to patient care. Amenities were graded using a scorecard (Table 3).

○ Areas for improvement were identified by comparison with the needs assessment document.

Improving lactation support at our institution via implementation of an institutional policy and facility upgrades.

• An evidence-based, ACGME-compliant lactation policy for trainees (Supplementary Data) was written by stakeholders, in concert with the resident and fellow advisory committee, and approved by the GME Program Council.

○ The policy details the responsibilities of the GME, training programs, and trainees.

○ Appropriate facilities, including temporary lactation rooms, are clearly defined.

○ Methods to ensure sufficient time for lactation and to foster a supportive workplace culture are outlined.

• A plan for facility upgrades was developed, and efforts to execute this plan are underway.

Controlling for process improvement by developing plans for evaluating policy utilization and potential for optimization.

• Policy efficacy will be monitored regularly by eliciting feedback from trainees and faculty.

• Policy adherence will be promoted through standardized employee education and dissemination of printed and online materials to improve awareness of available resources.

The project plan was structured according to the Six Sigma DMAIC process improvement methodology.

ACGME, Accreditation Council of Graduate Medical Education; DMAIC, Define Measure Analyze Improve Control; GME, graduate medical education.

Table 2.

Common Themes That Emerged from 2018 Feedback Sessions with a Focus Group of 10 Vidant Medical Center/Brody School of Medicine Trainees with Personal Experience Balancing Breastfeeding and Working as a Resident Physician or Fellow at Our Institution

Time constraints resulting in infrequent expression of breast milk

Desire to multitask while expressing milk

Variable degrees of support from faculty and colleagues

Limited awareness of existing lactation rooms

Difficulty accessing lactation rooms

Difficulty locating a safe place to store personal milk expression supplies and expressed breast milk

Table 3.

Scorecard for Designated Lactation Rooms at Vidant Medical Center, Developed in 2018 Based on Grading Systems Used by Federal and State Organizations

Basic model	Better model	Best model
Keypad access	Same as basic	Badge access
Door locks from the inside	Same as basic	Same as basic
Sign on door indicating whether room is occupied	Same as basic	Online system with real-time occupied/vacant status
Wheelchair accessible	Same as basic	Same as basic
Comfortable chair	Same as basic	Same as basic
Table next to chair	Same as basic	Same as basic
Electrical outlet by chair	Same as basic	Same as basic
Sink, soap, and paper towels	Same as basic	Same as basic
Disinfectant wipes	Same as basic	Same as basic
Trash can	Same as basic	Same as basic
Sign specifying point of contact for maintenance	Same as basic	Same as basic
Employee brings own pump	Employer provides multiuser breast pump	Same as better
		Employer provides personal pump kit (one per employee)
Refrigerator in room	Same as basic	Same as basic
	Hooks on the wall	Same as better
		Lockers for storing personal supplies
		Telephone to enable multitasking
		Computer with access to EHR to enable multitasking

Sources: U.S. Department of Health and Human Services³⁴ and Beth et al. 2013.³⁵

Overall grade:

One point for each item in “Basic” column, 2 for each item in “Better,” 3 for each item in “Best.”

A: 17+ points

B: 14–16 points

C: 11–13 points

D: ≤10 points.

Defining key terms in the ACGME requirement

The stakeholder team established collaborative definitions of key terms in the ACGME requirement to mitigate ambiguity and align expectations. To ensure consistency with accepted standards, we reviewed terminology utilized in federal¹² and state¹³ laws about breastfeeding, as well as language from federal¹⁴ and state¹⁵ guidelines for supporting lactation in the workplace. Final definitions of key terms were ultimately included in our institutional policy as an Appendix A in Supplementary Data.

Measuring the needs of lactating trainees

First, we sought to understand the general needs of lactating trainees in the nation by reviewing the literature about breastfeeding during graduate medical training. Multiple reports^16–20 document that despite high rates of breastfeeding initiation, many trainees struggle to maintain breastfeeding upon return to work following maternity leave and ultimately fail to meet national and global recommendations for breastfeeding duration. This literature review identified three key modifiable risk factors: insufficient time and flexibility in work schedule, poor access to appropriate places to express milk, and inadequate support from attendings and colleagues.

We next sought to measure the specific needs of lactating trainees at our institution. The resident representative on the stakeholder team identified and sought feedback from a focus group composed of current and recently graduated residents and fellows with personal experience balancing breastfeeding and working as a trainee at our institution. Among 22 invited to share their perspectives, 10 (45.5%) elected to participate in an advisory committee. Feedback sessions revealed that the key challenges faced by trainees at our institution are congruent with those reported nationally. Common themes are highlighted in Table 2.

Finally, the resident and fellow advisory committee conducted a formal needs assessment. The results were summarized in a document delineating specific amenities needed in lactation rooms, a comprehensive list of clinical locations requiring lactation rooms, and a description of supplementary components of an ideal lactation support program.

Analyzing our institution's current resources for lactating women and identifying areas for improvement

The stakeholder team identified the following resources available to breastfeeding employees at VMC, including trainees: 12 designated lactation rooms throughout the hospital campus equipped with multiuser breast pumps, free personal accessory kits for these pumps, free outpatient appointments with an IBCLC, and weekly breastfeeding support groups. We were unable to locate VMCs employee lactation policy for several months despite accessing the website dedicated to hospital policies and using the search terms “lactation” and “breastfeeding.” A brief statement, modeled after the Fair Labor Standards Act Break Time for Nursing Mothers Provision, was eventually located within the policy on meal and rest periods. This policy does not address several aspects of the new ACGME requirement, including refrigeration capabilities and proximity to patient care.

Utilization of VMC resources for breastfeeding employees is neither currently tracked nor are all resources publicized through common hospital communication sources, such as a website or the employee intranet. Most trainees expressed lack of awareness of these resources, including unfamiliarity with the locations of many designated lactation rooms. Furthermore, many trainees reported difficulty accessing lactation rooms when needed due to heavy use by other employees and patients and shared that they often pumped in nondesignated spaces such as call rooms or bathrooms.

A walk-through of VMCs designated lactation rooms was conducted to assess their amenities and locations. Findings were compared to the resident and fellow advisory committee's needs assessment inventory. Results were summarized in a scorecard based on grading systems utilized by federal²¹ and state¹⁵ organizations (Table 3). The majority of the room amenities scored in the “basic model” category, with a few ranking in the “better” or “best” categories. Several trends were observed, including widespread lack of refrigeration capabilities and a paucity of rooms equipped with a telephone and/or computer, to facilitate multitasking, as suggested by the ACGME.^1,2 The physical distribution of lactation rooms was assessed by measuring the time required to walk from common clinical locations to the nearest lactation room. Several were observed to be remote from clinical responsibilities, and none was identified in outpatient clinics or off-campus sites. Potential spaces for additional rooms were also evaluated during the walk-through.

Improving lactation support at our institution via implementation of an institutional policy and facility upgrades

The stakeholder team agreed that lactation support for trainees at our institution would be improved by formalizing a written policy that elaborates the specific responsibilities of all participating parties (GME, training programs, and trainees). With the goal of creating an evidence-based policy that addresses the needs of lactating trainees and meets ACGME requirements, we set forth to clearly define an appropriate lactation space, outline methods to ensure adequate time for lactation, and establish strategies for fostering a supportive work culture.

We reviewed expert guidelines for supporting breastfeeding mothers at work by The Academy of Breastfeeding Medicine²²; best practice guidelines for lactation room design by the American Institute of Architects²³; and Centers for Disease Control and Prevention^24,25; and U.S. Food and Drug Administration²⁶ recommendations for safe breast milk storage and breast pump maintenance. Next, we sought out examples of model policies by investigating whether other training programs, affiliated universities, or health care systems have existing lactation support programs, including review of wellness policies and human resources benefits. This search revealed that while many universities, including the one with which our hospital is affiliated, have publicly accessible employee lactation policies, there are fewer health care systems with such policies, and only a handful of programs with trainee specific published policies.

Feedback on the first draft of the policy was solicited from the resident and fellow advisory committee. A subsequent draft of the policy was reviewed with all of the program directors at the monthly GME Program Council meeting and received unanimous approval at the subsequent meeting. The current version of the policy (Supplementary Data) is currently under consideration by the GME Committee.

In addition to a policy, facility upgrades were deemed essential for improving lactation support. The stakeholder team discussed potential strategies for ensuring that trainees have access to appropriate lactation facilities, including updates to existing designated lactation rooms as well as creation of new lactation spaces. It was determined that both approaches are necessary to ensure adequate accessibility and compliance with ACGME requirements. Efforts are underway to secure space and financial commitments from institutional leadership to take the lead on updating current rooms to benefit not only trainees but also other employees, patients, and visitors.

As many training programs at our institution have off-campus clinics and/or rotations, it was determined that individual programs are best suited to assess the availability of lactation facilities for trainees working in these clinical locations. To support programs in identifying suitable locations, standardized requirements were developed and included in the policy as an Appendix B in Supplementary Data. Existing spaces can be utilized in a multipurpose capacity and serve as temporary lactation rooms. When in-use for lactation purposes, these spaces may be designated through use of a standardized sign. A call room, for example, may be an appropriate temporary lactation room as it is private, contains a sink for washing hands and breast pump parts, includes a telephone and/or computer to facilitate multitasking, and can be upgraded to satisfy ACGME refrigeration requirements with the simple addition of a compact refrigerator. This pathway for creation of a temporary lactation space has already been utilized by trainees.

Controlling for process improvement by developing plans for evaluating policy utilization and potential for optimization

Work is ongoing to ensure the success of our process improvement efforts. The control plan entails cyclical reevaluation of the policy for efficacy and stability. The response plan is based on the Plan-Do-Study-Act (PDSA) quality improvement method to address any new areas identified as requiring optimization. To monitor compliance with the policy, we will elicit feedback from trainees and faculty at regular intervals. To promote adherence to the policy, we will incorporate standardized education at new employee orientation and annual education requirements for current employees. To improve awareness of lactation resources, we will disseminate information about lactation resources during the return-to-work clearance appointment at Occupational Health required following parental leave. In addition, we will create a dedicated webpage on the GME website to publicize the trainee policy and centralize the availability of resources on the hospital websites, including electronic publication of the list of current lactation rooms. In addition to tracking website hits, we will collect data about lactation room and breast pump supply kit utilization. We also intend to reconvene a follow-up cohort of trainees and stakeholders to assess usability and identify further opportunity for improvement.

Discussion

In response to the new requirements for supporting lactating resident physicians and fellows, a validated process improvement methodology was utilized to improve lactation support for trainees at our institution. One of the highlights of this initiative was the creation of an evidence-based, ACGME-compliant lactation policy through stakeholder collaboration. These efforts may assist other institutions in responding to the call to action for a universal lactation policy for residents and fellows.²⁷

While several U.S. training programs have developed departmental lactation policies,^7–9 this is the first report of an institutional policy intended to support all residents and fellows based on the new ACGME requirements. Given the significant time and effort required to develop and institute a departmental policy, implementation of an institutional policy at the GME level would facilitate rapid support for a significant number of trainees in an efficient manner. Timely adoption of a lactation policy for residents and fellows is crucial given the observed disparities in breastfeeding success of female physicians and the fact that females comprise 45.4% of all current U.S. residents.²⁸

The American Academy of Family Physicians (AAFPs) recently published guidelines to assist institutions in developing lactation policies for medical students, residents, and fellows.²⁹ These comprehensive recommendations were issued after the approval of our institutional policy and thus were not available at the time of our literature search for evidence-based guidelines. However, our policy has many features in common with the AAFP guidelines. The structure of our policy adheres to the AAFPs suggestion that written documents delineate the responsibilities of administrators, trainees, and supervisors. In addition, both documents include minimum requirements for lactation rooms, specify the necessary time for lactation, and emphasize the importance of a supportive workplace culture.

In contrast to the University of Michigan Department of Surgery guidelines for lactating residents,⁸ both our policy and the AAFP guidelines²⁹ state that trainees should have the option to utilize a wearable breast pump in the operating room. This option may mitigate the challenge of balancing milk expression needs and surgical responsibilities, which is cited by surgical trainees as a major barrier to meeting breastfeeding milestones.³⁰ Given that surgical residents report shorter breastfeeding duration and access to fewer lactation resources than obstetrics and gynecology residents,³¹ strategies to promote equity across specialties are essential.

This report focuses on the methodology of our process improvement project and is limited by lack of outcome measures. Although an important first step, a policy is only one aspect of a comprehensive lactation support program. The next phase of our project is focused on addressing the areas for improvement identified by our needs assessment. Specifically, we are currently working to increase awareness of resources, develop educational materials, and upgrade lactation facilities. We are collecting data on lactation room utilization and anticipate completion of our first PDSA cycle in the coming months.

As the impact of our policy depends on adherence, our efforts to increase awareness of lactation resources and improve education are of paramount importance. Further research is needed to determine the most effective ways to educate trainees and attendings on the importance of actively supporting lactating colleagues. Informational handouts, such as the one developed by the University of Michigan Department of Pediatrics, may prove to be effective educational tools for this purpose.⁷ We anticipate that the most significant challenge will be achieving a cultural shift. As such, we plan to follow published recommendations for promoting gender equality³² and overcoming implicit bias.³³

Realization of plans for facility upgrades is essential for our initiative to reach its full potential. Although commitments from institutional leadership have not yet been secured, we anticipate success in this endeavor as the existence of multiple lactation resources demonstrates a desire on the part of the hospital to support breastfeeding employees. It remains to be determined whether competing needs of the various users of our hospital's lactation rooms will affect upgrade plans. For example, while trainees would benefit from having a refrigerator in the room to improve efficiency and minimize time away from clinical responsibilities and educational opportunities, patients may be better served by storage of expressed breast milk in separate refrigerators on their unit so that milk is more readily accessible and can be regulated similarly to a medication. Conflicts such as these can be effectively addressed through our continuous quality improvement efforts, thereby ensuring sustainability of our initiative. Alternatively, as recommended by the AAFP, separate spaces could be designated for trainees and patients.²⁹

Limitations of our process improvement project relate to its conduction at a specific institution, which may have a unique organizational structure and/or employee needs relative to other facilities. Less complex health systems may be able to satisfy ACGME requirements by establishing a single designated lactation room without the need for a policy that defines appropriate temporary rooms. Despite this limitation, as our policy was written in an evidence-based manner with the intention of dissemination, it should thus be suitable for modification and implementation by other GME departments.

Conclusions

Supporting breastfeeding is not only an ACGME mandate but also a public health priority. We welcome GME departments across the nation to utilize and adapt our institutional lactation policy for their resident physicians and fellows.

Footnotes

Acknowledgments

The authors thank the Office of GME, East Carolina University's Brody School of Medicine and Vidant Medical Center; Herbert G. Garrison, MD, MPH; Donna Brooks, IBCLC; Bennett Wall, MBA; and the residents and fellows on the Advisory Committee for their participation in and support of this process improvement project.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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