1

“If It’s Not Documented, It’s Not Done:”

Measuring Success in the Ten Steps

Objective

By the end of this session, participants will be able to

identify documentation and data collection methods that

are simple, user-friendly, cost-effective and meaningful.

2

Principle 1: It’s All About Best Practice

Principle 2: Exclusions

• Admitted to the Neonatal Intensive Care Unit for >4 hours during this hospitalization.

• ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for galactosemia as defined in TJCManual2015A1 Appendix A, Table 11.21

• ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for parenteral infusion as defined in TJCManual2015A1 Appendix A, Table 11.22

• Experienced death

• Length of stay >120 days

• Enrolled in clinical trials (related to feeding)

• Transferred to another hospital

• Born at <37 weeks gestation (≤36.6weeks)

3

Principle 3: If & Why

Each data element should say 2 things:

Principle 4:

Comprehensive Definitions

4

Principle 5: Design for EASY

Data Collection(See Handout)

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Measuring the Ten Steps

Measures: Expected Monthly

1. Skin-to-Skin: Vaginal Birth

2. Skin-to-Skin: Cesarean Birth

3. Rooming-In (Non-Separation)

4. Safe Formula-Feeding Instruction

5. Breastfeeding Initiation Rate

6. Exclusive Breastfeeding Rate

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Measures: Pick 2+

• Prenatal Education

• Breastfeeding Assessment and Support

• Hand Expression Instruction

• Milk Expression Instruction, NICU Mothers

• Pacifier Use

• Bottle-Top Use

• Post-Discharge Support

Breastfeeding Initiation

Percent of infants who receive mother's own milk at

least once during hospital stay (from birth to discharge)

7

Charting Initiation

[Newborn Record]

[Component] Clinical Documentation

[Sub-Component] Ins & Outs

[Field] Food [DD]

• Direct Breastfeeding

• Donor Human Milk

• Expressed Mother’s Milk

• Formula

• Water – D5

• Other: [Free Text]

Breastfeeding Initiation: Sample

8

Calculating BF InitiationNumerator

+ Born in time period of analysis

+ I&O: Breastfeeding ever selected

+ I&O: Expressed mother’s own milk ever selected

Denominator

+ Born in time period of analysis

Exclusive Human Milk Feeding

i.e. Joint Commission PC05

Percent of infants receiving human milk feedings

exclusively throughout hospital stay (from birth to

discharge)

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Charting Exclusivity:

I&O AND Provider Order

[Newborn Record]

[Component] Provider Order / I&O

[Field] Food [Drop Down]

• Breastfeeding

• Donor Human Milk

• Expressed Mother’s Milk

• Formula

• Water – D5

• Other: _____________

[Field] Supplement Reason [Drop Down]

• Admission Plan – Mixed Feeding

• Admission Plan – Exclusive Formula-Feeding

• Clinical Indication

• Counseled Maternal Request After First Feed

Calculating Exclusivity (PC05)

NUMERATOR

+ Born in time period

- Newborn’s I&O: Formula selected

- Newborn’s I&O: Other selected

DENOMINATOR

+ Born in time period

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Skin-to-Skin – Vaginal Births

Percent of infants born vaginally who are placed skin-

to-skin with their mothers immediately after birth, and

continue uninterrupted until completion of first feeding

(or for ≥ 1 hour if exclusively formula-feeding)

Charting Skin-to-Skin

Immediate Initiation of Skin-to-Skin

• Yes

• No, Maternal Clinical Indication

• No, Neonatal Clinical Indication

• No, Maternal Refusal After Counseling

• No, and none of above indications

Delayed Initiation of Skin-to-Skin

• …..

Cessation of Skin-to-Skin

• Stopped after first breastfeeding

• Stopped after one hour, exclusively formula-feeding

• Stopped, Maternal Clinical Indication

• Stopped, Neonatal Clinical Indication

• Stopped, Maternal Request After Counseling

• Stopped without above indications

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Skin-to-Skin: Sample

Skin-to-Skin: Sample

12

Calculating Skin-to-Skin Vaginal

NUMERATOR…

+ Born vaginally in time period

- Delivery Summary: “No, none of above indications” selected

- Delayed Initiation: “No, none of above indications” selected

- Cessation: “Ended prematurely for other reasons” selected

DENOMINATOR

+ Born vaginally in time period

Rooming-In

Percentage of dyads rooming-in throughout the entire

hospital stay.

13

Charting Rooming-In

Separations Tab in Newborn Care

• Location of Newborn [DD]

• Location of Mother [DD]

• Reason for Separation

• Maternal Clinical Indication [DD]

• Newborn Clinical Indication [DD]

• Maternal Request, After Counseling [DD]

• Other [You may list acceptable and unacceptable

options.]

• Duration of Separation

• ID Bands Match

Rooming-In: Sample

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Rooming-In: Sample

Calculating Rooming-In

NUMERATOR…

+ Born in time period

- Separations: Reason for Separation: “Other reasons not listed above”

selected

DENOMINATOR

+ Born in time period

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Safe Formula Use

Percent of mothers who have decided to feed formula

who receive individual counseling regarding risks and

benefits of feeding options, and instruction on safe

formula preparation and feeding

Charting Safe Formula Use

Newborn’s I&O

Selecting “Formula” triggers cascade

• Patient Education [DD]

• Risks of formula

• Risks of not breastfeeding

• Safe formula preparation

• Safe formula feeding

• Supplementation Route [DD]

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Safe Fx Instruction: Sample

Calculating Safe Fx Use InstructionNumerator: Option 1

+ Born in time period of analysis

- I&O: Formula NEVER selected

- Instruction: Any topics under “Formula-Feeding” are NOT selected prior to discharge

Numerator: Option 2

+ Born in time period of analysis

- I&O: Formula NEVER selected

- Instruction: Infant Feeding Handout Reviewed: “Yes, Mixed Feeding” or “Yes, Exclusive Formula-Feeding” NEVER selected

Denominator

+ Born in time period of analysis

- I & O: Formula NEVER selected

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Principle 1: It’s All About Best Practice

Principle 2: Exclusions

• Admitted to the Neonatal Intensive Care Unit for >4 hours during this hospitalization.

• ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for galactosemia as defined in TJCManual2015A1 Appendix A, Table 11.21

• ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for parenteral infusion as defined in TJCManual2015A1 Appendix A, Table 11.22

• Experienced death

• Length of stay >120 days

• Enrolled in clinical trials (related to feeding)

• Transferred to another hospital

• Born at <37 weeks gestation (≤36.6weeks)

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Principle 3: If & Why

Each data element should say 2 things:

Principle 4:

Comprehensive Definitions

19

Principle 5: Design for EASY

Data Collection(See Handout)

Objective

By the end of this session, participants will be able to:

identify documentation and data collection methods that

are simple, user-friendly, cost-effective and meaningful.

20