Regarding Perinatal Core Measure:

I agree, implementing the PC-05 core measure has been a struggle, but I do think it is a positive step forward in getting more people in the medical community aware of the importance of breastfeeding. I would love to also hear about the experiences and thoughts of others in implementing this core measure. On a side note, I'm curious if anyone else has had the experience that many MDs, RNs, administrators and QI department personnel seem to be laboring under the mistaken impression that I work for JHACO? That I have somehow created this core measure to torment them? Or is it just me?

Please correct me if I'm wrong, but this is my take on it so far. Much of the confusion may have been because the core measure was originally the PC-05, which was just simply going to be looking at the total number of all patients (excluding some with medical conditions and transfer to NICU, etc) and the total number of those who exclusive breastfed and reporting the percentage. Then late in 2013, hospitals were given the option of choosing either PC-05 or PC-05a (my guess because of backlash against the core measure) which also allows hospitals to exclude from data collection any mother who after receiving information about the benefits of breastfeeding, chooses formula feeding. 

So many hospitals seem to have jumped at this idea, thinking that their statistics would look much better. However, they didn't really realize that it would make the data collection process much, much more complicated. With PC-05a you are allowed to exclude women who chose formula feeding, but now you have to document that education was given prior to the first feed in the infant's chart. This is a challenge because usually the infant's chart is not created until the infant is born, sometimes 1-2 hours after birth depending on how busy we are. And mother's feeding plan needs to be acknowledged by the MD or LC or Nurse Practitioner prior to discharge from the hospital. So the documentation involved in PC-05a is much more complex. Hospitals thought that this would be the better choice, but I'm not so sure. What is happening instead is that many are failing to meet the documentation criteria, so many hospitals are now having a high rate of non-compliance
 with the core measure criteria, and this looks even worse than reporting a high supplementation rate. Reporting a fairly high supplementation rate is not the worst thing in the world, reimbursement is not tied to it yet, and the point is to make us aware of it so that we can begin working on reducing it. What you really want to show is improvement. It seems like this would have been the much simpler option.

So then JHACO only had from late 2013 to the January 1, 2014 implementation deadline to provide information about implementing the PC-05a core measure. If you are implementing PC-05a, it's my understanding that many hospitals have had a lot of confusion about how to document this core measure to meet the correct criteria, so you are not alone. I have sent three different emails to JHACO through this process for clarification, and they have been very helpful every time. If you have a specific question, I really recommend emailing them because they are very helpful. They did provide instructions on their JHACO website and the USBC put out a booklet that gave a lot of really good information. However, a few important details were missing, such as what qualifications they require for an LC. Turns out they need to be either a CLC or IBCLC. So JHACO recently issued a memo to clarify some of the missing information, and they stated that they will provide more
 information in August. 


One other problem that I have noticed seemed to contribute to the confusion is that the information that the QI department (those that collect the data from the charts) received was not nearly as clear as the detailed information that OB received. QI was lacking much of the information about data collection at first, because on their forms it simply asked if their was charting from the MD/LC/RN regarding mother's feeding choice. So QI naturally thought that RN charting was sufficient. They use an ORYX reporting system. This ORYX system did not provide them with the necessary information to correctly pull the data. We found at first this created confusion between OB and QI that took us months to clear up. Did anyone else have this problem? 

Another big problem we've had is the RN really understanding what mom's intention is during the hospitalization. We have an additional challenge that many of our patients do not speak English. And if the RN charts that mom intends to exclusively breastfeed, when she has no intention of exclusively breastfeeding and then she supplements with formula, you are going to have really bad statistics. So you really clearly need to understand what mom's intention is during hospitalization. You also need to clearly document education to the mother from RN, and acknowledgement of the feeding plan by the MD. So to do this we have created a form that mom receives with her hospital admission consents. It provides education about benefits of exclusive breastfeeding, allows her to choose her feeding plan, and the RN and MD both sign the form to acknowledge the feeding plan and that education was provided. The form needs to be signed by mom and RN prior to first feed,
 and by MD prior to discharge.

So we've had to struggle for awhile to understand what is required for documentation, and get QI and OB on the same page, and implement something that facilitates communication between mother, RN and MD which meets criteria for documentation. However, in the end, I think it's worth it. Now mothers are receiving more education about breastfeeding and providers (although many are resistant at first) are becoming more aware of benefits of breastfeeding. This core measure is doing what it needs to, getting their attention. However, change is always difficult, for some more than others. I would also love to hear about the experiences of others in implementing this important core measure.

Tricia Shamblin, RN, IBCLC

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