The Joint Commission (JC) that accredits many hospitals in the US has made some changes to collecting data for the Rate of Exclusive Breastfeeding in hospitals as of Oct 1, 2015. First, now all hospitals with more than 300 births per year are going to need to report this, instead of 1100 births per year. 



Originally, JC wanted to just measure the overall rate of exclusive breastfeeding (PC-05) but then there was an outcry among some who said it's not fair because what if mom doesn't want to breastfeed? So at the last minute PC-05A -which is a data collection that eliminates those women who did not want to breastfeed was also created within a couple months of starting the data collection. But rolling things like that out at the last minute was a real problem I think. It didn't really give them enough time to plan the documentation well. Hospitals were really confused about how to collect the data, many of them fudged the numbers instead of focusing on how to improve their support of breastfeeding. Many QI departments were really confused about who they could eliminate from data collection and mistakenly eliminated more women than they should. It was a mess and the numbers were meaningless. Anyway, so they are dropping PC-05A and going with what the JC originally wanted, just the PC-05. 
Also, they have actually made it easier for PC-05 because they are dropping the exclusions for maternal medical contraindications because they state that it just creates more confusion and paperwork and the rate of women who meet that criteria is really small, less than 2% (for example women who are HIV positive). I think it's good to still continue to chart those exclusions just because it is relevant to the mother's medical care, but it's not necessary for PC-05 anymore. Additionally, JC does not expect this number to be 100% but they feel that 70% is an achievable goal for hospitals. With half of their hospitals falling below 50% on this measure. 
So here is the information from their manual from July 2015:https://manual.jointcommission.org/releases/TJC2015B1/MIF0170.html


Included Populations: Liveborn newborns with ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table 11.20.1Excluded Populations:   
   - Admitted to the Neonatal Intensive Care Unit (NICU) at this hospital during the hospitalization
   - ICD-10-CM Other Diagnosis Codes for galactosemia as defined in Appendix A, Table 11.21
   - ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for parenteral nutrition as defined in Appendix A, Table 11.22
   - Experienced death
   - Length of Stay >120 days
   - Enrolled in clinical trials
   - Patients transferred to another hospital
   - Patients who are not term or with < 37 weeks gestation completed

So it's my understanding that these are the babies that you can eliminate from your data collection and your data abstractors will do this automatically based on the ICD-10 codes used to code the babies charts. So you won't really need to do any type of specific charting to eliminate them from your data sets. And these do not seem to have changed from last year, so it's my understanding that you should not be including any babies under 37 weeks gestation. So 37.0 is included, but 36.6 weeks would not be included. Also, when they say NICU, that also includes SCN's in Level 2 hospitals. I wrote JC to clarify and what they said was that any baby that spends more than a couple hours in transitional care in the SCN (including full-term babies) should be excluded from data collection. So if the baby has TTN and is observed in the nursery for a couple hours, then is fine and goes back to moms room, you should include them if they are full-term. But if they are full-term and need to stay in the SCN for any length of time, then exclude them. Also excluded are babies who die, are transferred to another hospital, hospitalized for more then 120 days, in a research study, have galactosemia, or receive TPN. The only charting that will be required on perinatal units is keeping track of babies feeds, what they eat and who is getting breastmilk and who has formula, etc. 
One more thing about PC-05, as an LC I'm concerned about some things I hear happening at other hospitals in my area. I hear that some LC's are now being pushed by their management to fudge numbers or refuse formula or push patients harder to breastfeed "to get the hospitals numbers up." I'm really saddened and disappointed to hear that. I do think the core measure is a great idea. It's the first time I really see our hospital and Physicians beginning to understand that this important to the babies health. I would hope that hospitals would understand that the way that we increase our rates is by improving support and education of patients and staff, not forcing, pressuring or guilting them. Hospitals need to understand that this type of thing is only going to backfire and create dissatisfied customers that aren't going to return to them in the future. I understand these hospitals have good intentions on "breastfeeding support" but their execution is poor. The JC says over and over again that they want hospitals to improve their support of breastfeeding women to increase breastfeeding rates. I feel like some in management and administration still don't get it. When are these people going to get it? You can't just refuse to give a mom formula or throw a breast pump at the problem - you need to educate your staff! Okay, that was my rant for the day. Thanks for listening.
Tricia Shamblin, RN, BSN, IBCLC










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