This is the info I got from Carole Patterson, who is Deputy Director,
Department of Standards for JCAHO.  It comes from page PE-44 of the
Comprehensive Accreditation  Manual for Hospitals: the Official Handbook.

Nursing:  Example for PE.4, PE.4.1, and PE.4.3

One hospital formed a group to develop and review written guidelines for
assessing breastfeeding mothers throughout the course of pregnancy and their
infants after birth.  The group consisted of nurses from the postpartum unit,
the nursery, and those involved in teaching prenatal classes;  the lactation
consultant; nurse midwives, obstetricians; and pediatricians.  A variety of
resources such as Protecting, Promoting and Supporting Breast-feeding (sic):
the Special Role of fMaternity Services from the World Health Organization
(Yeah!,  my emphasis), and Standards of Practice for Lactation Consultants
developed by the International Lactation Consultant ASsociation were used to
define the scope of assessments and to identify assessment data to be gathered
during each phase.  Some of the breastfeeding assessment data included:
- family history related to breastfeeding
- pregnancy and birth history
- health history of the mother and infant
- lactation and breastfeeding history
- objective and subjective information about the health status of the mother
and
- objective and subjective information about the health status of the infant.

The group identified at which phase the data needed to be gathered and who
needed to be involved in the collection of the data.  The data and the
assessment forms were designed so that each person could add information to
the form.
___________________

It's not as extensive or specific as I hoped.  From the context I think it's
an example of problem identification and quality improvement process, but it
specifically mentions ILCA and WHO which I can now point out to my
neonatalogists!!!   It's a beginning.

Carole Patterson's e-mail address is: [log in to unmask]   (I hope some of
our learned and articulate lactnetters will write her and encourage an
expansion of these guidelines.)

Cindy N.