Why It Matters
For nearly 20 years the HealthySteps program has operated as part of the Advocate Family Medicine Center–Ravenswood, located in the heart of the Ravenswood community in Chicago. The Center meets the health needs of a diverse patient population, including a significant number of patients from the nearby community of Uptown, a neighborhood known as a point of entry for immigrants arriving in Chicago. Patient care is provided by a staff of 14 attending physicians; 2 nurse practitioners; 24 residents; and a complement of other health professionals, including our HealthySteps Specialist.
Breastfeeding consultation is among the critically needed services we provide. Research demonstrates the benefits of increased breastfeeding duration on the physical and social-emotional health of the mother and baby. Timely lactation counseling interventions to support new mothers are essential to ensure that the first breastfeeding attempts are successful. Also, the quality of the breastfeeding support is as important as the timing. New mothers want information about breastfeeding and what to expect, practical help positioning the baby to breastfeed, effective advice and suggestions, acknowledgment of their experiences and feelings, and reassurance and encouragement.
Because the hospital stay for labor and delivery is short, the time to interact with lactation counselors in the hospital is limited. Our practice includes a Newborn Clinic to support families as soon as they are discharged from the hospital and during the first few weeks after birth. We recognize that the newborn period is a time during which we can intervene if mothers need support with breastfeeding. The HealthySteps Specialist, who is also a certified lactation consultant, has the time and expertise to listen and respond to family concerns, to understand the family dynamic, and to observe how the residents are supporting and communicating with the parents.
Where We Started
We started by mapping our breastfeeding support process, which helped us identify natural points at which we could provide additional support. Next, we collected baseline data for 4 weeks to understand our breastfeeding duration rates. To gather this information, we administered the breastfeeding questionnaire provided by the HealthySteps National Office, and we added a question to capture reasons why a mother might discontinue breastfeeding. Baseline data showed that, while breastfeeding initiation was high (94.5%), there was a decline at the 2-month well-child visit, when 75% of mothers were still breastfeeding. At the 6-month well-child visit, 61% of mothers were still breastfeeding. Despite being above the Illinois state average of 53% of mothers continuing to breastfeed at 6 months, we thought we could improve our rate of breastfeeding duration at the 6-month well-child visit. Our team wanted to set an attainable target. Because longer term outcomes like breastfeeding can be more difficult to impact than short-term outcomes like increasing the rate of completed breastfeeding questionnaires, we reduced our original target from 75% to 65% prior to beginning our first PDSA (plan-do-study-act) cycle.
Our team developed this goal (SMART Aim): By December 31, 2019, the percentage of mothers who report continuing to breastfeed at the 6-month well-child visit will increase from 61% to 65%.
How We Diagnosed the Problem
After we had our baseline data, we explored the reasons mothers gave for discontinuing breastfeeding. At first, we believed that mothers discontinued because they had to return to work. Yet, when we looked at the data, the most common reason mothers shared for stopping breastfeeding was low milk supply. We revisited our breastfeeding support process map with the Outcome Pilot Project Evaluation Team and used the 5 whys technique to identify root causes for why mothers might discontinue breastfeeding because of low supply. Our team identified several factors associated with perceived or actual low milk supply, such as the introduction of formula, mother’s medical issues, and inconsistent education about breastfeeding. Ultimately, we thought that mothers may have limited knowledge on breastfeeding because information is not disseminated consistently, and providers may not want to push too much breastfeeding information on the family.
How We Tested Solutions
We identified change strategies by brainstorming potential interventions to address inconsistent education about breastfeeding. We developed a one-page handout on myths and facts about breastfeeding to distribute to all families during the newborn visit. Each week we tracked and documented the results of our change strategy using an Excel spreadsheet.
Over the 7 months of our continuous quality improvement (CQI) project, we tested the following change strategies:
Change Strategy #1: Residents provided families with a brief handout on the myths and facts about breastfeeding (adopted)—Drawing on existing resources, our HealthySteps Specialist worked with our lead physician and faculty to develop the breastfeeding handout (appendix A). The team obtained feedback from residents and attending physicians prior to testing the handout with families. Our HealthySteps Specialist then trained each resident on the purpose of the handout, goals of the project, and how to discuss the handout with families, slowly increasing the number of residents trained over a few weeks. Residents used the handout during the newborn visit to discuss breastfeeding myths and facts.
Change Strategy #2: Medical assistants verbally administered the breastfeeding questionnaire and entered responses into the electronic health record (adopted)—After 6 weeks of testing our change strategy, we noticed that our breastfeeding rates were being affected by breastfeeding questionnaires not being completed. To address this, we worked with our Information Technology (IT) team to build the breastfeeding questionnaire into our EHR, and we trained our medical assistants to verbally administer the questionnaire with families and enter responses directly into the EHR. See the CQI Snapshot of the breastfeeding survey data entry screen.
Although we did not reach our target, we were able to increase breastfeeding rates for infants at 6 months of age from 61% to 64%. To keep the momentum and sustain the gains we made, we integrated these change strategies into our daily practice and continue to monitor our data.
What the Experience Was Like
The project had several successes. We involved faculty and residents in the development of the handout. Residents have fully adopted using the handout when talking with families about breastfeeding. Our team also found that, by reviewing the data, residents changed how they engaged in conversations with mothers about breastfeeding, becoming even more intentional about discussing the introduction of formula. They set the tone up front by asking how the mother was doing, actually listening to what she had to say, and acknowledging her experiences rather than passing judgment or assuming her intentions. This approach helped engender trust and more genuine engagement as the residents explored reasons for discontinuing breastfeeding with mothers and focused on obtaining more detailed information about why mothers chose to use formula. The handout prompted more in-depth discussion between residents and mothers about how feeding frequently and pumping can help increase supply.
The CQI project was not without its challenges. It was difficult to schedule time with our team to discuss progress on the project. However, we found that quick check-ins via email worked well. Other challenges we experienced were related to completion of the breastfeeding questionnaire. Some medical assistants did not feel comfortable with administering the questionnaire verbally to patients, mostly because of feeling overwhelmed with the addition of another activity on top of the multiple ones they had to complete as they room the patients. Therefore, keeping track of families that did not complete the breastfeeding survey was challenging. We worked with the nurse supervisor who oversees the medical assistants to train them on the questionnaire and gain their buy-in for administering it verbally and entering responses into the EHR.
Our CQI Team
The Advocate Ravenswood HealthySteps CQI team consisted of our former Manager of Community Outreach and Population Health (Brittany Powell), HealthySteps Specialist (Catalina Ariza), HealthySteps Coordinator (Sasha Zaikova), Physician Champions (Drs. Jose Elizondo and Catherine Plonka), Nurse Coordinator (Jacklyn Kafka), and Practice Manager (Mary Zimmers).