Hospitals Work Together to Improve Breastfeeding in Texas

December 16, 2013
By Kristina Grifiantini

Erin Hamilton Spence

Erin Hemilton Spence, MD, is an advisor for the Dallas-area birthing centers in the Texas Ten Step Star Achiever Breastfeeding Learning Collaborative.

Watch Spence discuss the importance of milk banks and take NICHQ inside an exclusive video tour of the Mothers’ Milk Bank of North Texas.

Erin Hamilton Spence, MD, is a passionate breastfeeding advocate. Aside from working as a perinatal and neonatal specialist at Cook Children's Medical Center/Pediatrix, she also volunteers as the President of the Mothers’ Milk Bank of North Texas. She does all of that while also acting as an advisor for the Dallas-area birthing centers in the Texas Ten Step Star Achiever Breastfeeding Learning Collaborative, a breastfeeding improvement project run by the Texas Department of State Health Services (DSHS) and NICHQ. The project helps hospitals implement system changes that better support mothers who want to breastfeed, by helping them implement the Ten Steps to Successful Breastfeeding and move toward Baby-Friendly designation.

As the project wraps up its first phase of work with Dallas-based hospitals and moves to Houston and Austin-based hospitals, NICHQ caught up with Spence to ask her about what started her passion in breastfeeding advocacy and how hospitals in her advisory group have been making great strides by working together.

What prompted you to begin advocating for better breastfeeding support?

As a physician, you don’t get a whole lot of education about how hard breastfeeding is; you just understand how important it is in terms of long-lasting health benefits for both the mother and baby. There wasn’t any specific lactation training, at least not when I was in medical school 10 years ago. When I became a mother, I was shocked at how challenging it was for me to breastfeed in spite of the fact that I knew it was the right thing to do. It was one of the hardest things I’ve ever done. Being a nursing parent in the first two weeks was more exhausting than doing my residency. All my call nights and lack of sleep didn’t compare to being a parent those first two weeks and nursing around the clock.

The fact that breastfeeding was more challenging than anything else I had done made me want to help. I didn’t have anyone to tell me about problems to anticipate, or that it would get better. Now, as a mother of four, I understand it’s so important to share that knowledge in birthing centers since we don’t have broad cultural support. That’s why I do it.

What is the current status of breastfeeding support in Texas?

Before the collaborative, the Texas Ten Step certification was the only support offered to maternity facilities so this collaboration was a continuation on a larger scale. There were several hospitals who joined the collaborative that were already designated Baby-Friendly and were seeking re-designation. There were others who were interested in moving in that direction and some who hadn’t begun any changes at all. The collaborative has encouraged a grassroots effort to have the whole system become Baby-Friendly, which helps push the whole region forward and becomes a marketing initiative for the kind of high-quality care we provide.

How has the collaborative experience and quality improvement initiative helped this first group of Texas hospitals from your perspective?

It has been — across the board — a positive for all 20 hospitals in the first group, 11 of which I served as advisor to. It was really rewarding to see all of these hospitals together, exchanging ideas, all excited about the things they were doing well and interested in learning how to overcome their roadblocks. This initiative has not just increased breastfeeding education for those involved, but it also taught the broad quality improvement techniques necessary to get this sort of thing done. Improving care is so multifaceted that you really need a system to test and implement changes.

Something extraordinarily unique that I hadn’t seen before is to have all of these extremely competitive hospital systems come together to share best practices and tips to make a difference for all patients, not just patients that chose a particular hospital.

In terms of quality improvement techniques, it’s been really nice for everyone to see how you can focus on one thing, make a few small changes in a row, assess those changes and respond by making the change a part of your culture if it’s successful. This collaborative has been a tremendous boost to getting things done. The data collection piece in particular was something we couldn’t get our minds around because we didn’t have the tools. The QI tools that NICHQ gave us in the collaborative have been extremely helpful.

What are some of the accomplishments of the participating hospitals?

One of the most exciting things I’ve seen that grew out of the in-person sessions has been the sharing of knowledge around how to do skin-to-skin after a caesarean section. That’s probably one of the bigger successes of introducing the idea of skin-to-skin contact in the first 2-3 minutes—which has been proven to improve breastfeeding—because people at first felt like it was impossible to do at their hospitals. But through the collaborative, teams learned QI-based ideas of doing tiny environment and process changes to make the bigger change possible. For example, moving the intravenous pole from behind the mother’s arm to in front of her so she has access to her chest to hold and breastfeed the baby. Small things like that. A lot of the hospitals got really excited about the idea that you could make that a normal part of practice. And then they thought if you could go through this in the operating room, then doing it at vaginal delivery should be a piece of cake.

Aside from skin-to-skin, we continue to struggle — but have gotten much better – with rooming-in for 23/24 hours. This involved learning how to supply the pediatricians with the things they need to do exams in room and change the flow of nursing staff so babies come upstairs with the moms and stay with the moms. As we collected data at my hospital we had not realized, firstly, that we weren’t documenting our procedures very well, even the positive things. Once we saw we only had 15% instead of 80% compliance, we were shocked it was that low. Since then, we have made a whole lot of process changes, like providing practitioners and nurses with things they needed to do assessments. In the last few months things have changed dramatically and we are much more successful at keeping moms with babies around the clock. Those little pieces, like how to encourage people to do those things and get their buy-in, all came from the collaborative.

What have you felt has been the biggest success in this project?

At our second in-person meeting, I started to see people tell personal stories and open up more in terms of collaboration. I don’t know that anyone else on the team realized how astonishing this was because I had been beating my head against the wall for a long time trying to get hospitals to collaborate. I got so excited; it was such a surreal moment for me to be part of that through the efforts of NICHQ and the “Texas Trio” of state and WIC advisors (Tracy Erickson, Veronica Hendrix and Julie Stagg) who have really led this work.

That for me has been the biggest success: that hospitals have been able to reach across practices for better care for babies and not focus on who’s getting the most patients. Participants were seeing that all the teams were good at something and see that everyone has room for improvement, even those teams that were already Baby-Friendly. That was really encouraging to the smaller hospitals, especially because those not designatedey saw Baby-Friendly as an unattainable goal and now they were seeing that just being Baby-Friendly isn’t the end of the journey. Designation is a goal line, but not the end by any means.

As the collaborative nears its end for this group before focusing on Houston and Austin areas, what challenges remain for this first region?

The biggest challenge for this group as they move forward is to keep up the same pace of change that they’ve been able to accomplish through the collaborative. That will be interesting to see. I hope they have some acceleration and continue to maintain the pace of change they’ve put in place this last year.

A year is a short time span. I was pretty dubious that they would be able to make a whole lot of change in a year, but I’ve seen more change in this previous year than in the two and a half years my hospital had spent trying to make breastfeeding support changes. I’ve been really impressed that NICHQ has been able to accelerate the things we’ve learned and increase collaboration between hospitals.

What has your experience been working with NICHQ?

It’s really been unparalleled. It’s my first broad collaborative that had hospitals working together as opposed to working within their own systems. The teamwork and education and the structure they provide is not like anything I’ve ever seen. I was doubtful at first at how successful they would be planning it remotely, but I’ve been really pleased at all that NICHQ has accomplished from the east coast.

I feel like the faculty that NICHQ brought have been really great even compared to other QI faculty I had encountered in the past. And I saw firsthand the value of face-to-face group meetings (“learning sessions”), where people who hadn’t worked together before came together as a broad audience of parents, nurses, doctors and administrators. Gathering everyone together like this dramatically changes the things you’re capable of doing and the changes you can make, as opposed to a top-down approach.

Incorporating parent partners was also a helpful technique. From the beginning our parent partners were enthusiastic and understood their roles as the content experts for their birth experiences. That was not something that I’ve seen done successfully in any other way. Getting them to be part of the team was really important from the community perspective.

What advice would you give hospitals striving to improve their breastfeeding support, in Texas and elsewhere?

You have to put in the time and effort to make sure you have as high an administrator as possible on your side and an enthusiastic physician. They will think of systems-level change very differently than a parent partner, nurse or lactation consultant. And then of course you need the person who also has the time to make it matter and isn’t completely overwhelmed by all other things in their practice.