Author: Jillian Genereux

QI Implementation 101: A Primer for Race Dashboard Utilization and Next Steps for Breastfeeding Awareness Month

Race and ethnicity reporting can help hospitals and communities assure maternal health equity and respectful care, but a dashboard is just the beginning.

Elizabeth Rochin Ph.D., RN, NE-BC | August 18, 2022

Posted under: Data & Analytics, Quality of Care

A couple of weeks ago, I discussed the importance of race and ethnicity reporting, and how hospitals and communities can utilize that information to assure maternal health equity and respectful care.

A dashboard is just the beginning. A dashboard offers insight into your outcomes. So, what do you do with that data?

It’s time to initiate Quality Improvement within your organization to guide meaningful change. But there are important questions to ask yourself if QI is new to you, or if you need a refresher.

Have you ever thought about why quality improvement (QI) projects work in some units, and why they don't work in others, within the SAME SYSTEM? QI is all about rapid cycle improvement and data collection. Both are important aspects of patient care and elevating maternal health.

In units where QI works well and results are sustainable over time, what do you notice?

Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?
  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?
  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?
  • Do they routinely ask about outcome disparities?
  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?
  • How engaged is the Board in reviewing and understanding maternal health QI projects?
  • Do unit leaders have an opportunity to engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?
So, all things being equal, and leadership is on board with QI, let's continue to dive in…

Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?
  • What does physician leadership look like?
  • Do they work well together?
  • Are they committed to the same outcomes and priorities?
  • Are they committed to including the voices of those most impacted in perinatal project planning?
  • In other words, are patients of color or others based upon identified social needs asked to participate in QI initiatives within the unit?
  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?
  • Have they assessed the activation and readiness of their teams to engage in QI work?
Again, let's assume that unit leadership is on board. Diving further…

Frontline Care Teams
Let's explore the teams themselves, the team members who will be doing the work.
  • Are they ready to engage in QI work?
  • Are Doulas considered part of the frontline care team?
  • Did the team have any input in creating the QI project?
  • Are there identified champions and informal leaders?
  • Is there bandwidth available?
  • How many other projects and initiatives are underway?
  • Is this considered a priority among many others?
  • Is the team multidisciplinary and includes all facets of care?
  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

And diving EVEN further, assuming everything is lining up…

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?
  • Are the measures/objectives/metrics in line with the communities you serve?
  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
So, let’s use breastmilk exclusivity as an example (Joint Commission Core Measure PC-05). Why does one unit succeed and another one fail?

Hospital Leadership:
  • Awareness of maternal health core measures?
  • View as a priority within Joint Commission Core Measures and hospital strategic plan?
  • Frequency and evaluation of disparities in PC-05 and exclusive breastmilk feeding?
  • Rounding on units to assess for engagement? Barriers to implementation?
Nursing and Physician Leadership/Unit Level:
  • Agreement on the importance of breastmilk feeding?
  • Mutual support from RN/MD leadership?
  • Awareness and involvement of all team members to support the initiative, including other care team members involved in care? And yes, this includes Environmental Services, Case Management, Food and Nutrition Services, Biomedical Engineering, Pharmacy, Respiratory Therapy, and anyone meeting a patient. Does everyone buy into the importance of breastmilk feeding?
  • Students part of the process and encouraged to participate in and lead QI activities?
Frontline Care Team:
  • Does your frontline care team look like the patients you are serving? If not, what steps has your organization taken to diversify your team to ensure breastmilk feeding education is meeting the needs of your patients?
  • How are Doulas used in breastmilk feeding education?
  • Ongoing education? Is it Just-in-Time/bite size for ease of use?
  • Use of Lactation Consultants to promote real-time education?
  • How are QI Champions supported? Dedicated time for support of the QI project?
  • Understanding and appreciating the importance of evidence-based practice?
  • How are breastmilk feeding QI activities incorporated into daily processes? How are they communicated to teams? How do teams communicate initiatives and outcomes to each other?
Naysayers
  • Have they been heard? Have their concerns been addressed? Even if unable to meet the need, have the inability to provide (XXX) been discussed?
  • Are there not enough resources or supplies to support breastmilk feeding in the unit?
  • Are there personal biases against breastmilk feeding? Did a personal experience lead to anger or frustration surrounding breastmilk feeding? (VERY IMPORTANT!!)
  • Have any personal conscious/unconscious racial biases been addressed that may be creating negativity towards equity work?
Patients
  • Have diverse patients been included in providing feedback related to their breastmilk feeding experience?
  • Has the breastmilk feeding QI project been introduced to patients with feedback elicited prior to implementation?
  • Is a Patient Advisory Committee or Team included in the QI project and process for improving breastmilk feeding?
  • Have patients been asked about resources, supplies, and other needs related to breastmilk feeding?
  • Have patients had an opportunity to review any hospital documentation related to Community Health Needs Assessment (CHNA) related to breastmilk feeding? Did they have an opportunity to contribute their experiences or findings?
  • Can patients serve as volunteer support to encourage breastmilk feeding success?
Quality Improvement (QI) can provide many inroads to improvements in patient care, patient experience, and health equity. Knowing where to start once you have collected and shared your data is important.

I can speak to health disparities through data and data analytics, but not through lived experience. Knowing how to raise up and amplify those who are best suited to lead QI projects is of utmost importance and must be a priority if equitable maternal health is to be elevated and achieved for all.





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Breastmilk Feeding Awareness Week

Throughout the world, breastfeeding is recognized as a real and sustainable action to reduce infant malnutrition and enhance food security. Every August, the World Health Organization (WHO) and United Nations (UN) lead efforts to recognize importance of breastfeeding.

Elizabeth Rochin, PhD, RN, NE-BC | August 4, 2022

Posted under: Maternal Health, Other

Yes, notice I wrote Breastmilk Feeding Awareness Week…we’ll get back to that shortly.

Every August, the World Health Organization (WHO) and United Nations (UN) lead efforts to recognize and support the importance of breastfeeding throughout the world. In fact, August 1 -7 historically is considered to be World Breastfeeding Awareness Week. Throughout the world, breastfeeding is recognized as a real and sustainable action to reduce infant malnutrition and enhance food security, In fact, many organizations worldwide recognize this week as the celebration of the anniversary of the 1990 Innocenti Declaration, the UNICEF Declaration on the Protection, Promotion, and Support of Breastfeeding.

There are many initiatives across the United States to support the importance of breastfeeding during this awareness week and month, including supporting laws and legislation to make breastfeeding more available and normalized in our society; highlighting significant racial and ethnic disparities in breastfeeding initiation and sustained efforts through infancy; and promoting the undisputed health benefits for both mother and baby.

Congress Finally Takes Action for Its Own…In 2018
On April 18, 2018, the United States Senate voted unanimously to allow newborns on the Senate floor with their parent. Senator Tammy Duckworth had given birth one month earlier and wanted to bring her newborn daughter to the Senate floor to cast her vote. Up until that time, no newborns were allowed in the Senate chambers. And later that April day, Senator Duckworth brought her newborn with her to cast her vote and would continue to bring her daughter with her for Senate business. When asked if she had plans to breastfeed her daughter on the Senate floor, Senator Duckworth responded:

“I’ll do whatever I need to both do my job and take care of my daughter. That’s what most moms and dads would do. The rule change also allows a male senator to bring his newborn onto the floor if he wants to bottle-feed.”

There were many within the public forum that deeply appreciated Senator Duckworth’s sentiments and comments. And finally, the United States Senate made the very appropriate decision to allow breastfeeding on the Senate floor to allow mothers to continue to support their newborns and their constituents (this also brings up the topic of paid family leave to support bonding and breastfeeding, but that is another blog topic). There were also those who were diametrically opposed to “bottle-feeding” and wanted to address the use of the term “bottle-feeding” in that context and were concerned of the unintentional impact on breastfeeding, and if some would see Senator Duckworth’s statements as a form of promoting bottle-feeding rather than breastfeeding.

So, Back to Breastmilk Feeding Awareness Week
Over time, we have also come to realize that babies are fed breastmilk in varied ways, and not simply through the breast. There are many circumstances whereby newborns and babies are fed breastmilk, including: (not exhaustive):

  1. Newborns in the NICU who receive pumped breastmilk via artificial nipple, orogastric or nasogastric tube, syringe, cup, or other devices.

  2. Parents who have returned to work and are pumping breastmilk to feed their newborn via artificial nipple.

  3. Adoptive families.

  4. LGBTQ+ families.

  5. Survivors of sexual trauma.

These are just a few of the reasons parents may not be able to breastfeed, but still want to offer their newborns the benefits of breastmilk. And while there has been overwhelming research to support and promote the nutritional and physical benefits of breastfeeding, we cannot ignore the fact that babies may be fed breastmilk by means other than a breast. Chestfeeding is also becoming normalized in infant nutrition and must be considered within these important discussions.

The use of donor human milk (DHM) could be its own blog discussion. There are for-profit, not-for-profit, and other breastmilk banking companies, as well as online communities that facilitate breastmilk sharing. The Human Milk Banking Association of North America (HMBANA) accredits nonprofit milk banks throughout the US and Canada and is a resource for parents across the United States (and has become a much more visible organization with the recent infant formula shortage).

Speaking of donor human milk (DHM), it is also very important to consider the disparities that exist with the use of DHM and location. For example, safety net hospitals, or those with higher Medicaid utilization, tend to use less DHM than other facilities. Interestingly, 14 states and the District of Columbia have enacted legislation to cover the use of DHM for very low birth weight babies and for specific conditions. The costs of purchasing donor human milk can be very prohibitive and providing breastmilk nutrition to families seeking its nutritional value should not be seen as a luxury.

Therefore, I’d like to propose a change to Breastmilk Awareness Week, or Breastmilk Feeding Awareness Month. We must widen our aperture to be more inclusive and aware of the benefits of breastmilk feeding for families who may not be able to feed their baby directly from the breast for any variety of reasons. We shame women enough…for breastfeeding in public, taking too many breaks to express breastmilk, not breastfeeding long enough, or for too long, or (you fill in the blank). We must also be mindful of the advocacy to ensure the availability of donor breastmilk for non-NICU families that is not out of reach due to cost.

We have spent the past few months having very deep and passionate conversations about women’s bodies and women’s choices. If a parent wants to feed a baby breastmilk via the breast, artificial nipple, syringe, cup, or another feeding device, we should welcome and support their choice.

Welcome to Breastmilk Feeding Awareness Month.

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Homelessness Is Not Neglect

One of the challenges of addressing homeless families is that there have been many definitions of what “homeless” means over the years. The National Center on Family Homelessness reports that families make up 37% of the homeless population.

Elizabeth Rochin, PhD, RN, NE-BC | July 26, 2022

Posted under: Maternal Health, Social Determinants of Health/Disparities

Last week, I came across a story from the Los Angeles Times entitled, Pregnant, Homeless, and Living in a Tent: Meet Mckenzie. I read the article with genuine interest, as our National Perinatal Information Center Perinatal Database reveals that homelessness is one of the most reported social determinants of health (SDOH).

In the story, a young woman, Mckenzie, describes her experiences as a homeless teen during her pregnancy. She worries about having to disclose her housing situation to case managers and social workers at the hospital when she goes into labor, fearful that her baby will be taken into protective custody based on her housing status.

One of the lines in the article quickly caught my attention: Homelessness is Not Neglect.

According to Mckenzie, one of her social workers did not associate homelessness with neglect, and merely the location of living.

According to the Child Welfare Information Gateway, neglect is frequently defined as “the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm.” So, does living in a tent meet this definition if all other needs are satisfied? Should it?

Voices Across the Nation
Last week, I reposted that article on LinkedIn and received messages from across the United States regarding experiences working with homeless mothers and the often kneejerk reactions to immediately contact Protective Services about their homelessness:

“Members of our team immediately called CPS on a Black mother for being homeless. She left AMA during labor, and we do not know where she delivered. I was so distraught. Our current policy directs us to contact CPS for homeless parents. Like they have not been traumatized enough already. We must change our policies to protect these mothers, and to make every effort to keep these newborns with their mothers”—Southeast US

“We assign blame to these mothers. Homelessness ‘must have been their choice.’ They did something to lose their home, their livelihood.’ With this kind of mindset, we will never help these women. We will simply continue to blame them”—West Coast US
“We make it impossible for women to seek help when they are experiencing homelessness. And too many care providers assume that homelessness is some permanent situation. There must be better answers”—West Coast US

“We treat convicted prisoners who deliver and give birth with more compassion than we do those who are homeless. We make great efforts to keep the mother and baby together during incarceration, but do not allow the same effort for the homeless mother. What does that say about us, and the value we place on those who are experiencing homelessness?”—Mid-Atlantic US

Homeless Families

One of the challenges of addressing homeless families is that there have been many definitions of what “homeless” means over the years. However, most states now are using the US Department of Housing and Urban Development definition, which describes a person who lacks a fixed, regular, and adequate nighttime residence.

The National Center on Family Homelessness reports that families make up 37% of the homeless population. And within those homeless families, 52% are Black, and 35% are white, according to the most recent Annual Homeless Assessment Report to Congress. The mere fact that the National Center on Family Homelessness needs to exist should give everyone pause.

According to the National Partnership for Women and Families, there are significant disparities that exist within homelessness:
- Pacific Islanders are 14 times more likely to experience homelessness than white people
- Native Americans are nearly 6 times more likely
- Black people are nearly 5 times more likely
- Black and Latina renters are disproportionately threatened with eviction

Seeking Safety, Seeking Refuge
So how do women become homeless in the first place? Domestic and sexual abuse is the primary driver for women fleeing their homes, with children in tow, to escape abuse. Studies on homelessness report that nearly 90% of homeless women have experienced sexual or physical trauma. But homeless women also have many other needs that may not be addressed during an experience with homelessness, such as pregnancy, breast health, support for menses, and other issues. In fact, a Massachusetts report on homelessness reported that women are more likely to opt out of shelters for fear of their physical safety, and therefore are not counted and are underrepresented in many estimates of homeless women. Homeless mothers experience chronic and repeated traumas that can impact both the mother and the child in irreparable ways.

So, What Can You Do?
Advocacy for access to care is not a one-and-done event. Advocating for equitable, sustainable, and compassionate services to support homeless women and their families is of the utmost importance in our communities. Just as important is advocating for resources for those who are on the brink of homelessness…just one paycheck away from having nothing.

So, before you pick up the phone and call Child Protective Services to initiate a report for neglect, have you already made every effort to secure the unmet social needs of your pregnant patient? If not, why not? Do you initiate Child Protective Services reports equitably and equally? And if not, why not? Do you track the race and ethnicity of your Child Protective Services reports based on the rationale for the call? Do you share that data with your care teams?

“Members of our team immediately called CPS on a Black mother for being homeless. She left AMA during labor, and we do not know where she delivered. I was so distraught. Our policy directs us to contact CPS for homeless parents. Like they have not been traumatized enough already. We must change our policies to protect these mothers, and to make every effort to keep these newborns with their mothers."

So, I return to this statement. What could have been done differently? How could we have kept this pregnant woman in the hospital and connected her with the services she needs to take care of her newborn? How could we better engage? How can we reframe our biases and eliminate racism within our healthcare settings to provide respectful and dignified care to all patients?

Homelessness is Not Neglect…until you say it is.
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NPIC’s Race & Ethnicity Dashboard

For years, clinicians, researchers, and community members have been describing the disparities in perinatal and obstetric outcomes, particularly within race and ethnicity. In 2020 NPIC set forth an initiative to bring to life, a Race & Ethnicity Dashboard.

Elizabeth Rochin, PhD, RN, NE-BC | July 18, 2022

Posted under: Data & Analytics, Maternal Health, Social Determinants of Health/Disparities

For many years, clinicians, researchers, and community members have been describing the disparities in perinatal and obstetric outcomes, particularly within race and ethnicity.

In 2017, National Public Radio (NPR) and ProPublica launched the Lost Mothers series, which sought to put the names and faces to those who died of pregnancy complications, such as stroke, hemorrhage, heart failure, among other causes.

In 2019, Dr. Elizabeth Howell and colleagues recommended the use and implementation of race and ethnicity quality dashboards as “one of eight steps for narrowing gaps in maternal outcome disparities.”

And in 2020, NPIC set forth an initiative to bring this race and ethnic disparity dashboard to life. During 2020, NPIC worked with a diverse team comprised of representatives of member hospitals to establish the framework and initial metrics that would best serve healthcare teams in identifying and acting upon obstetric and neonatal outcome disparities.

So, what were the initial metrics that were chosen by this group? The metrics that were selected include:

Maternal
- Cesarean Section
- Postpartum Hemorrhage
- Severe Maternal Morbidity Overall (including and excluding blood transfusion)
- Severe Maternal Morbidity, Hemorrhage (including and excluding blood transfusion)
- Severe Maternal Morbidity, Hypertension (including and excluding blood transfusion)

Neonatal
- Severe Complications in Term Newborns (Overall, Severe, Moderate)
- Neonatal Bloodstream Infection
- Birth Trauma
- NICU/Special Care Discharges

One year ago this month, NPIC published an overview of the development of the Race and Ethnicity Dashboard, including initial findings from a cohort of 335,412 maternal discharges, and 322,592 neonatal discharges. Here are some of those key findings, which continue to support the literature and other studies:

1) Cesarean Section rates are highest in Black women.

2) Rates of Medicaid utilization, the average length of stay, and case mix index are the highest in Black and Native American populations.

3) Rates of Postpartum Hemorrhage and Severe Maternal Morbidity (overall) are highest in Black and Native American populations.

In response to the work that was conducted, NPIC also created the NPIC Perinatal Quality and Equity Framework that can be utilized in a multitude of settings, including inpatient obstetric care areas. This framework includes areas such as:

1) Including Voices of the Community when creating dashboards and analytics that reflect community outcomes.

2) Recognition of the data, and conducting a routine multidisciplinary review.

3) Patient safety operations and the sustainability of a Patient Safety Nurse/Obstetric Safety Nurse within obstetric leadership teams.

4) Accuracy of race and ethnicity data, including data transparency and cultural competency when handling demographic data.

5) Hospital-sensitive equity indicators that are co-created by multidisciplinary teams, including community voices.

6) Patient reported outcome metrics (PROM) that explore experiences in care, including respectful care, racism, marginalization, mistreatment, or other key patient-reported outcomes.

7) Social Determinants of Health (SDOH) data collection that is purposeful, sustainable, and creates a community-needs assessment and action plan. There should NEVER be a “blame and shame” culture for circumstances that are shared with healthcare teams.



Last week, Vice President Kamala Harris and her team published the White House Blueprint for Addressing the Maternal Health Crisis. NPIC fully supports this blueprint and the actions required to elevate and transform maternal health in the United States.

Goal 3 of the Blueprint is to Advance Data Collection, Standardization, Transparency, Research, and Analysis. This is an outstanding goal and one that NPIC fully supports. In fact, NPIC has years of data that can provide additional substance to this goal:

* NPIC has over two (2) years of stratified race and ethnicity data providing hospitals with data that can be a critical component of community action plans for reducing and eliminating outcome disparities.

* Over 20 years of linked mother/baby data that can offer insights into what impacts the health of the mother has on newborn outcomes.

NPIC partners with hospitals, research organizations, payers, and other companies to provide data that can inform real solutions. Our hope is that hospitals across the United States will embark on their own journey to reduce and eliminate outcome disparities. With the standardization of care, respectful care models, patient activation, shared decision-making, and patient-team-based communication, care equity within obstetric and neonatal populations can be realized.

Where are you on your obstetric care equity journey?
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