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Date
*Name of Facility
Number of births per year
*Contact Person
*Title
*Credentials
*Phone
*Email
Mailing Address
Breastfeeding Rate Information
What are your breastfeeding rates*?
Initiation (%)
Rate of any breast milk feeding at discharge (%)
Rate of exclusive breastmilk feeding at discharge (%)
*The percentage of all term, singleton, non-NICU infants who received any amount of breastmilk through direct breastfeeding or alternative feeding method. Please use your latest TJC PC-05 report if possible.
Has your facility completed the CDC's Maternity Practices in Infant Nutrition and Care (mPINC) survey?
Yes
No
Latest year submitted
Score
Lactation Support Information
Number of IBCLCs
Number of days with IBCLC coverage (i.e. 5 days a week)
Percent of Staff who have completed an 18-hour Breastfeeding Education Course that follows the BFHI suggested outline
Percent of Staff that have completed a 40-hour course specific to breastfeeding education
Staff Education Information
18 contact hours of breastfeeding education is required for all Maternal Infant staff within 6 months of employment?
Yes
No
Number of hours of breastfeeding education required for all staff members each year?
Additional Information
1. What percent of your mothers are taught the importance of exclusive breast milk feeding prior to delivery? This includes counseling/education received from WIC, obstetrician, office nurse, Medicaid Care Coordinator, as well as education received by L&D nurse up until the time of delivery.
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
2. What percentage of your infants are placed skin-to-skin within 5 minutes of delivery? Refusal of STS should be documented, along with a valid reason. Mother refusal of STS is not a valid indication. Teaching to provide STS should be that the majority of your mothers will agree to participate in this important aspect of infant stabilization.
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
3. What percentage of the mothers in your care initiate breastfeeding within the first hour following delivery?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
4. What percentage of the stable mothers in your care who are separated from their infants (i.e. premature infant) are taught hand expression within the first hour of delivery?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
5. What percentage of the mothers in your care are provided with basic instruction on breastfeeding within 6 hours of delivery?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
6. What percentage of your infants are supplemented without a medical indication documented in the chart? Charts may be counted in compliance if the mother requests supplementation and the nurse provides education regarding the risks of supplementation. This education must be properly documented in the chart to be compliant.
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
7. What percentage of your mothers and infants are together 23 out of 24 hours a day?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
8. What percentage of the mothers in your care are given education of Safe Sleep prior to discharge?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
9. Prior to discharge, what percentage of the mothers in your care are given a number to call if they are having breastfeeding problems after discharge and referred to a mothers' breastfeeding support group?
Less than 10%
10%-30%
31%-50%
51%-70%
71%-100%
We do not keep up with this metric
10. Does your facility have a breastfeeding task force or perinatal review committee?
Yes
No
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