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  • Measure Summary
  • NQMC:010797
  • Jul 2016
  • NQF-Endorsed Measure

Perinatal care: percentage of newborns that were exclusively fed breast milk during the newborn's entire hospitalization.

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Specifications manual for Joint Commission national quality core measures, version 2015B. Oakbrook Terrace (IL): The Joint Commission; Effective 2015 Oct 1. 327 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of newborns that were exclusively fed breast milk during their entire hospitalization.

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization.

Rationale

Exclusive breast milk feeding (BF) for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG (2007) has recently reiterated its position. A recent Cochrane review substantiates the benefits (Kramer & Kakuma, 2002). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) BF (Centers for Disease Control and Prevention [CDC], 2007; Petrova, Hegyi, & Mehta, 2007; Shealy et al., 2005; Taveras et al., 2004). Exclusive breast milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health for the last several years using newborn genetic disease testing data. Healthy People 2010 and the CDC have also been active in promoting this goal.

Evidence for Rationale

American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007 Feb;109(2 Pt 1):479-80. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). Breastfeeding trends and updated national health objectives for exclusive breastfeeding--United States, birth years 2000-2004. MMWR Morb Mortal Wkly Rep. 2007 Aug 3;56(30):760-3. PubMed External Web Site Policy

Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002;(1):CD003517. [107 references] PubMed External Web Site Policy

Petrova A, Hegyi T, Mehta R. Maternal race/ethnicity and one-month exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeed Med. 2007 Jun;2(2):92-8. PubMed External Web Site Policy

Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC guide to breastfeeding interventions. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005. 67 p.

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

Taveras EM, Li R, Grummer-Strawn L, Richardson M, Marshall R, Rego VH, Miroshnik I, Lieu TA. Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 2004 Apr;113(4):e283-90. PubMed External Web Site Policy

Primary Health Components

Exclusive breast milk feeding; newborns

Denominator Description

Single term newborns discharged alive from the hospital (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Newborns that were fed breast milk only since birth

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Breastfeeding is associated with decreased risk for many early-life diseases and conditions, including otitis media, respiratory tract infections, atopic dermatitis, gastroenteritis, type 2 diabetes, sudden infant death syndrome, and obesity. Breastfeeding also is associated with health benefits to women, including decreased risk for type 2 diabetes, ovarian cancer, and breast cancer (Ip et al., 2007). Exclusive breastfeeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines (World Health Organization [WHO], 1991).
  • In 2007, Healthy People 2010 objectives for breastfeeding initiation and duration included two new objectives on exclusive breastfeeding to increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60% and through age 6 months to 25% [objectives 16-19d and 16-19e] (U.S. Department of Health and Human Services [DHHS], 2000). The Healthy People 2020 objectives for exclusive breastfeeding were continued through age 3 months with a goal of 46.2% and age 6 months with a goal of 25.5% [objectives MICH-21.4 and MICH-21.5]. Also included is the related objective MICH-24: increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies (DHHS, 2010).
  • The Centers for Disease Control and Prevention (CDC) developed a Guide to Breastfeeding Interventions in 2005 for the promotion and support of breastfeeding based on detailed input from the spectrum of breastfeeding experts which can be used to help hospitals achieve the Healthy People 2020 objective MICH-24. Institutional changes, i.e., attaining Baby Friendly Hospital Initiative status, individual interventions including increased rooming-in of mothers and newborns, early skin to skin contact and discontinuing policies that are not evidence based have been shown to increase breastfeeding initiation and duration rates as well (Shealy et al., 2005). According to the CDC (2011), mothers who want to breastfeed who do not receive hospital support will stop early. The CDC encourages hospitals to partner with Baby-Friendly hospitals to learn how to improve maternity care, use the CDC's Maternity Practice in Infant Nutrition and Care (mPINC) survey data to prioritize changes to improve maternity care practices and stop distributing formula samples and give-aways to breastfeeding mothers.

Evidence for Additional Information Supporting Need for the Measure

Centers for Disease Control and Prevention (CDC). Hospital support for breastfeeding: preventing obesity begins in hospitals. CDC vital signs. [internet]. 2011 [accessed 2011 Sep 26].

Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. [internet]. Rockville (MD): U.S. Department of Health and Human Services; 2007 [accessed 2011 Sep 27].

Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC guide to breastfeeding interventions. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005. 85 p.

U.S. Department of Health and Human Services (DHHS). Healthy people 2010. [internet]. Washington (DC): 2000 [accessed 2011 Sep 26].

U.S. Department of Health and Human Services (DHHS). Healthy people 2020. [internet]. Washington (DC): 2010 [accessed 2011 Sep 26].

World Health Organization (WHO). Indicators for assessing breastfeeding practices. [internet]. Geneva, Switzerland: World Health Organization (WHO); 1991 [accessed 2011 Sep 27].

Extent of Measure Testing

Twenty-six contracted performance measurement systems (PMS) agreed to support the perinatal care measures. Joint Commission staff defined and developed a database structure for electronic receipt of measure data and a verification process was implemented to assure that measures were embedded into the measurement system's technical infrastructures and into their data collection tools in accord with Joint Commission specifications. Joint Commission staff also verified data collection tools and provided education regarding the performance measure set to PMS vendors, who in turn provided education and ongoing support to their contracted hospitals.

Once sufficient data to support this effort were received by The Joint Commission, a reliability assessment of the measures and individual data elements was conducted from October 2011 through January 2012. A data collection tool was developed to facilitate the reabstraction of selected medical records and assessment of the reliability of the data elements. Reliability test site visits were conducted by Joint Commission staff at a subset of 12 randomly-selected hospitals. Selection of the sites was based on multiple characteristics, including hospital demographics, bed size and type of facility.

In the course of the reliability site visits, electronic and paper medical records were blindly reabstracted by Joint Commission staff. Reabstracted data elements were then compared with the hospital's originally abstracted data on a data element to data element basis. Differences in abstraction were investigated and adjudicated in order to understand the reasons for any disparities. In addition, structured focus group discussions were held at each site to gather additional feedback on the measures. A resource evaluation was also completed the site visit hospitals to assess the cost and time associated with data collection effort. Feedback from the focus group discussions has been incorporated into the measure

Evidence for Extent of Measure Testing

Domzalski K. (Associate Project Director, Division of Healthcare Quality Evaluation, Department of Quality Measurement, The Joint Commission, Oakbrook Terrace, IL). Personal communication. 2013 Sep 20.

State of Use

Current routine use

Current Use

Accreditation

Collaborative inter-organizational quality improvement

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Newborn

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

Discharges July 1 through December 31

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Liveborn newborns discharged alive from the hospital with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Principal Diagnosis Code for single liveborn newborn (as defined in the appendices of the original measure documentation)

Exclusions

  • 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 the appendices of the original measure documentation)
  • International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) Principal Procedure Code or ICD-10-PCS Other Procedure Codes for parenteral nutrition (as defined in the appendices of the original measure documentation)
  • Experienced death
  • Length of Stay (LOS) greater than 120 days
  • Patients transferred to another hospital
  • Patients who are not term or with less than 37 weeks gestation completed

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
Newborns that were fed breast milk only since birth

Exclusions
None

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Perinatal Care (PC) Initial Patient Population Algorithm Flowchart
  • PC-05: Exclusive Breast Milk Feeding Flowchart

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

Internal time comparison

Original Title

PC-05: Exclusive breast milk feeding.

Measure Collection Name

National Quality Core Measures

Measure Set Name

Perinatal Care

Submitter

The Joint Commission - Health Care Accreditation Organization

Developer

The Joint Commission - Health Care Accreditation Organization

Funding Source(s)

No external funding was received.

Composition of the Group that Developed the Measure

The Perinatal Care Technical Advisory Panel (PC TAP) recommended which National Quality Forum (NQF)-endorsed Perinatal Care measures should be included in the set. Members of the PC TAP are enumerated at: http://www.jointcommission.org/assets/1/18/TAP_Members_Web_List.pdf External Web Site Policy.

Financial Disclosures/Other Potential Conflicts of Interest

Expert panel members have made full disclosure of relevant financial and conflict of interest information in accordance with National Quality Forum (NQF) and The Joint Commission's Conflict of Interest policies, copies of which are available upon written request to The Joint Commission.

Endorser

National Quality Forum

NQF Number

0480

Date of Endorsement

2014 May 1

Core Quality Measures

Obstetrics and Gynecology

Measure Initiative(s)

Hospital Inpatient Quality Reporting Program

Adaptation

This Perinatal Care measure has been adapted from the following National Quality Forum (NQF)-endorsed measure:

  • Exclusive Breastfeeding During Birth Hospitalization [California Maternal Quality Care Collaborative]

Date of Most Current Version in NQMC

2016 Jul

Measure Maintenance

Every six months

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Specifications manual for Joint Commission national quality core measures, version 2015B. Oakbrook Terrace (IL): The Joint Commission; Effective 2015 Oct 1. 327 p.

Source(s)

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

Measure Availability

Source available from The Joint Commission Web site External Web Site Policy.

For more information, contact The Joint Commission at One Renaissance Blvd., Oakbrook Terrace, IL 60181; Phone: 630-792-5800; Fax: 630-792-5005; Web site: www.jointcommission.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by The Joint Commission on January 15, 2010 and reviewed accordingly by ECRI Institute on February 8, 2010.

This NQMC summary was completed by The Joint Commission on November 16, 2010 and reviewed accordingly by ECRI Institute on March 30, 2011.

This NQMC summary was retrofitted into the new template on June 30, 2011.

This NQMC summary was completed by The Joint Commission on September 20, 2013 and reviewed accordingly by ECRI Institute on November 15, 2013.

This NQMC summary was completed by The Joint Commission on July 21, 2014 and reviewed accordingly by ECRI Institute on September 22, 2014.

This NQMC summary was updated by ECRI Institute on October 7, 2015. The information was verified by the measure developer on October 19, 2015.

This NQMC summary was updated again by ECRI Institute on June 14, 2016. The information was verified by the measure developer on June 29, 2016.

Copyright Statement

The Specifications Manual for Joint Commission National Quality Core Measures [Version 2016A, July 2016] is periodically updated by The Joint Commission. Users of the Specifications Manual for Joint Commission National Quality Core Measures must update their software and associated documentation based on the published manual production timelines.

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