Promoting Breastfeeding through a Statewide Quality Collaborative

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Case Report:

The Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide quality improvement collaborative founded in 2009. Members elected to develop a project to address Tennessee’s low breastfeeding rates.

The project aim is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting breastfeeding at prenatal care visits. The short-term project goal is to increase the fraction of infants who are fed breastfmilk at the maternal post-partum visit by 50% by March 2012.

A toolkit of evidence-based practices was developed by an interdisciplinary project development team through a combination of face-to-face meetings and webinars. Published tools from the AAP, ACOG, ABM, and elsewhere were reviewed to complete this toolkit. Inclusion of a practice in the toolkit was based on evidence of effectiveness and consensus/approval by the project development team and pilot centers. Toolkit format and project protocols were designed to be consistent with other TIPQC projects. The target population for this project includes expectant mothers presenting for routine prenatal care in the outpatient clinic. Project outcomes will be measured at the first postpartum visit at 4-8 weeks post-delivery. The project pilot was launched in three TN practices in spring 2011.

Participating practices will first establish a primary improvement team that includes relevant stakeholders and a project champion and team leader. Ongoing project support will be provided through regional learning session and webinars. In recognition of the range of needs and varied resources across the state, the toolkit includes a menu of “potentially better practices” (PBPs) that may be implemented individually, or as a bundle. Success of this project relies on high reliability (>90%) implementation of processes that promote breastfeeding in the prenatal clinic and the use of rapid Plan-Do-Study-Act (PDSA) cycles. Use of a web-based data-entry system through REDCap will allow practices to access on-demand run-charts and control charts for their project data as well as automated comparisons to project-wide aggregate data. The fractions of mothers’ exclusively feeding breastmilk, feeding both breastmilk and formula, and feeding exclusively formula at the first post-partum visit at 4-8 weeks post-delivery will be determined. The fraction of mothers with infants readmitted to the hospital after birth will be tracked as a balancing measure. Local audits will be used to evaluate reliability of implementation of potentially better practices.


This project may serve as a model for how quality improvement methodologies may be combined with use of distance-learning and web-based data entry and reporting to facilitate dissemination and measured implementation of potentially better practices across a broad geographic region with highly diverse populations. The approach has the potential to increase breastfeeding rates and improve health and could be modified for application in delivery and postnatal settings.


Boston, MA

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