Using mpinc as a Tool for Improvement Jennifer M. Nelson, MD, MPH Medical Epidemiologist Centers for Disease Control and Preven/on USBC Power Tools January 18, 2017 Na/onal Center for Chronic Disease Preven/on and Health Promo/on Division of Nutri/on, Physical Ac/vity, and Obesity mpinc Survey Launched in 2007 Administered every 2 years Census of all hospitals and birth centers BreasHeeding-related maternity care pracjces and policies Key informant Response rate >80% Benchmark report Total Score 7 domain sub-scores Using mpinc as a Tool for Improvement 1
Average Total mpinc Scores, 2007-2015 Year Total Score 2007 63 2009 65 2011 70 2013 75 2015 79 Total mpinc Score, by state, 2015 DC Puerto Rico National average: 79 Range: 60-96 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Using mpinc as a Tool for Improvement 2
Hospitals in our state have many barriers in implemenjng evidence-based maternity care.resistant doctors, formula supplementajon, skin-to-skin care in the operajng room.just to name a few. How can we improve our overall mpinc score? Hospital A: Safety-Net Hospital Medically underserved populajon 25-35% uninsured; 40-60% underinsured Average annual income: <$15,000 96% Hispanic and Spanish-speaking 69% nulliparous Additional risk factors Safety-net hospital Remote location o Challenge to acquire physician and nurse resources 5,000 births (pre-2008) à 3,500 births (2012) o decrease in admissions was an administrator s nightmare Total mpinc score 65 (2011) à 92 (2013) How?? Using mpinc as a Tool for Improvement 3
Hospital A: SoluJon Maternal-Child Nurse Managers Sought and acquired knowledge on Baby- Friendly Hospital Initiative (BFHI) and mpinc survey Memberships to lactation organizations obtained o Obtained ideas and information Utilized BFHI Guidelines and mpinc survey o External benchmarks and defined data collection processes Plan-Do-Study-Act (PDSA) model Plan Do Act Study Hospital A: Selected Challenges Staff Training Trained 443 individuals and verified 5,035 hours of training Established on-going process for training and education Beyond required 20 hours to develop own experts Newborn Hypoglycemia Protocol Worked with pediatric team All newborns è routine only for at-risk or symptomatic newborns o Reduced glucose testing for 46% of newborns Non-breast milk products Los dos ( the two ) Nurse education Maternal choice form Chart review for nursing/physician documentation Electronically linking formula distribution to individual staff Using mpinc as a Tool for Improvement 4
Hospital A: Results Vaginal deliveries 97% had skin-to-skin contact 92% received breast milk as first feed 95% mother-infants transferred together Stable C-secJons 40% were couplets o 90% had skin-to-skin contact o 83% received breast milk as first feed o 91% mother-infants transferred together Exclusive BreasHeeding rates 16% (2012) à 42% (2015) Total mpinc score 65 (2011) à 92 (2013) Hospital A: Keys to success A change process that was driven by nurse leaders with the authority, mojvajon, and resources to move pracjce forward Having 3 nurses pass the IBCLC exam Strong message of success to the entire nursing staff Data collecjon plan crijcal for early and ongoing success Multi-team process o Each unit leader played a role in data collection Customized form to capture BFHI and mpinc data elements o Initiated in L&D, used for patient hand-off o Data abstracted daily, analyzed monthly Using mpinc as a Tool for Improvement 5
.the mpinc survey provided external benchmarks used to guide the transformation of our maternity care and to define our data collection processes. Eganhouse, DJ, et al. Becoming Baby-Friendly and Transforming Maternity Care in a Safety-Net Hospital on the Texas-Mexico Border. Nurs Womens Health. 2016;20(4):378-90. *Logo credit: http://www.umcelpaso.org/webshell/umcep.nsf/defaultframeset/site+defaults?opendocument&docid=8e164b0dde46203887256d85006daa51 mpinc Sub-Scores Using mpinc as a Tool for Improvement 6
Average Labor & Delivery Care Sub-Scores, 2007-2015 Year Total Score 2007 59 2009 63 2011 70 2013 80 2015 85 Labor & Delivery Care mpinc Sub-score, by state, 2015 DC Puerto Rico National average: 85 Range: 65-98 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Using mpinc as a Tool for Improvement 7
The Iowa Experience: Increasing Access to BreasHeeding Friendly Hospitals Iowa s Labor & Delivery Care sub-score: 50 (2007) à 85 (2015) Skin-to-skin (Cesarean births): 16% à 73% Procedures performed skin-in-skin: 9% à41% Iowa Department of Public Health Targeted rural hospitals with large proportion of Medicaid births Met with key stakeholders Reviewed policies and mpinc results Hosted training (6 Steps 4 Success) Additional efforts in 4-5 hospitals annually o Rural location with large proportion of Medicaid births o mpinc score less than state average o Assistance in reviewing mpinc results o Determine opportunities for improvement o Develop improvement plan for > 2 dimensions of care h]p://healthyamericans.org/health-issues/preven/on_story/increasing-access-to-breas_eeding-friendly-hospitals-the-iowa-experience/ Average Feeding of BreasHed Infants Sub-Scores, 2007-2015 Year Total Score 2007 76 2009 78 2011 81 2013 84 2015 86 Using mpinc as a Tool for Improvement 8
Feeding of Breastfed Infants mpinc Sub-score, by state, 2015 DC Puerto Rico National average: 87 Range: 68-97 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) California County- and Region-specific Benchmark Reports h]ps://www.cdph.ca.gov/data/sta/s/cs/pages/californiampincsurveydata.aspx Using mpinc as a Tool for Improvement 9
h]ps://www.youtube.com/watch?v=exq0d05ldxw Average BreasHeeding Assistance Sub-Scores, 2007-2015 Year Total Score 2007 79 2009 81 2011 84 2013 86 2015 89 Using mpinc as a Tool for Improvement 10
Breastfeeding Assistance mpinc Sub-score, by state, 2015 DC Puerto Rico National average: 89 Range: 80-100 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Massachusefs MA s BreasHeeding Assistance Sub-score: 86 (2007) à 95 (2015) Using standard assessment tool: 68% à 93% Rarely providing pacifiers: 35% à 74% Massachusefs Baby-Friendly CollaboraJve 4 facilities applying for Baby-Friendly designation Goal: to assist hospitals in achieving the Ten Steps by sharing information, ideas, support, and encouragement Summarized recommendations and specific actions taken o Use existing tools to make small steps that really count o Keep pacifiers in a locked medication system Bar/ck, M, et al. The Massachuse]s Baby-Friendly Collabora/ve: Lessons Learned From an Innova/on to Foster Implementa/on of Best Prac/ces. J Hum Lact. 2010;26(4):405-11. Using mpinc as a Tool for Improvement 11
The mpinc survey offers an important opportunity for gathering internal stakeholders to complete the survey together and discuss what practices could be improved as well as brainstorm ways to change those practices in terms of attaining specific score gains for changed practices. It can serve as the missing catalyst to unite staff to improve performance on a specific goal tied to 1 or 2 questions on the mpinc survey. Bartick, M, et al. The Massachusetts Baby-Friendly Collaborative: Lessons Learned From an Innovation to Foster Implementation of Best Practices. J Hum Lact. 2010;26(4):405-11. 1/18/2017 Average Mother-Infant Contact Sub-Scores, 2007-2015 Year Total Score 2007 67 2009 71 2011 74 2013 79 2015 83 Using mpinc as a Tool for Improvement 12
Mother-Infant Contact mpinc Sub-score, by state, 2015 DC Puerto Rico National average: 83 Range: 62-96 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Working for Equity in BreasHeeding in the Maternity Services of Puerto Rican Hospitals Yvefe Piovanel, Cindy Calderon, Gisela Castaner 2015 AAP conference abstract (Washington, DC) Puerto Rico (PR) Mother-Baby Summits Breastfeeding Coalition of the PR Health Department 67% of hospitals represented Goals: o Encourage mpinc participation o Encourage improved maternity care practices Initial Assessment 12-month Follow-up mpinc Participation 8 hospitals (<30%) 12 hospitals (42%) Breastfeeding policy 85% 94% Rooming-in offered 75% 95% h]ps://aap.confex.com/aap/2015/webprogrampress/paper29421.html Using mpinc as a Tool for Improvement 13
Average Discharge Care Sub-Scores, 2007-2015 Year Total Score 2007 40 2009 43 2011 49 2013 62 2015 68 Discharge Care mpinc Sub-score, by state, 2015 DC Puerto Rico National average: 69 Range: 36-98 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Using mpinc as a Tool for Improvement 14
Percentage of Hospitals DistribuJng Infant Formula Discharge Packs, mpinc 2007-2015 % of hospitals distributing packs % point change 2007 2009 2011 2013 2015 (2007-2015) Total 72.6 65.8 54.5 31.6 21.3-51.3 Nelson, JM. et al. Trends in the prevalence of U.S. hospitals distribu/ng infant formula discharge packs to breas_eeding mothers from 2007 to 2013. Pediatrics 2015. Average Staff Training Sub-Scores, 2007-2015 Year Total Score 2007 51 2009 51 2011 57 2013 62 2015 64 Using mpinc as a Tool for Improvement 15
Staff Training Sub-score, by state, 2015 DC Puerto Rico National average: 64 Range: 35-91 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Tennessee BreasHeeding Tool Kit Staff Training Sub-score: 47 (2007) à 63 (2015) h]p://www.healthytennesseebabies.com/toolkit.aspx Using mpinc as a Tool for Improvement 16
Average Structural & OrganizaJonal Aspects of Care Delivery Sub-Scores, 2007-2015 Year Total Score 2007 66 2009 69 2011 71 2013 74 2015 77 Structure & Organizational Aspects of Care Delivery Sub-score, by state, 2015 DC Puerto Rico National average: 77 Range: 60-97 1/18/2017 > 90 80-89 70-79 < 70 Island Territories (American Samoa, Guam, Saipan, and the U.S. Virgin Islands) Using mpinc as a Tool for Improvement 17
Texas Ten Step: How Texas Hospitals Can Reduce Obesity Through BreasHeeding Policy Structure Sub-Score: 59 (2007) à 71 (2015) Model policy: 7% à 32% h]p://texastenstep.org/wp-content/uploads/2012/11/right-from-the-start-2011.pdf 2015 mpinc data availability Hospital-specific Benchmark Reports Hard copies mailed to: o Hospital Administrator/CEO o Director of Obstetrics o Director of Pediatrics o Director of Quality Improvement o Mother-Baby Nurse Manager o Survey recipient Questions: mpinc@cdc.gov State-specific Reports Emailed to state-level organizations and others Available: https://www.cdc.gov/breastfeeding/data/mpinc/state_reports.html NaJonal Web Tables Available: https://www.cdc.gov/breastfeeding/data/mpinc/results-tables.htm Using mpinc as a Tool for Improvement 18
Conclusion Hospital pracjces are improving Total and subscores increasing ConJnued areas for improvement Staff Training Structural and Organizational Aspects of Care Future direcjons Completely revised questionnaire o Web only Target 2018 launch http://bit.ly/2bga14f For more informajon please contact: jmnelson@cdc.gov 1600 Clifon Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.cdc.gov Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info The findings and conclusions in this report are those of the authors and do not necessarily represent the official posi/on of the Centers for Disease Control and Preven/on. Na/onal Center for Chronic Disease Preven/on and Health Promo/on Division Nutri/on, Physical Ac/vity, and Obesity Photo credit: http://pediatric-house-calls.djmed.net/breastfeeding-human-milk/ Using mpinc as a Tool for Improvement 19