Improving Statewide Breastfeeding Rates through the Learning Collaborative Model

Posted March 06, 2015 by Kristen Holmstrand

Veronica Hendrix
Veronica Hendrix, LVN, IBCLC, RLC, program coordinator for the Texas Ten Step Program.

The state of Texas is considered a national leader in their innovative use of breastfeeding initiatives and campaigns. As early as 1999, the Department of State Health Services (DSHS) and the Texas Hospital Association jointly developed the Texas Ten Step Program, which helps hospitals and birthing facilities begin to address and implement the WHO/ UNICEF’s Ten Steps to Successful Breastfeeding.

In 2012, DSHS through funding provided by the Supplemental Nutrition Program for Women, Infants, and Children (WIC), launched the Texas Ten Step Star Achiever Initiative. This project further established the DSHS/WIC commitment to improving maternity care practices and breastfeeding support for mothers and babies. Following a quality improvement model, the Star Achiever Initiative offers a NICHQ-led learning collaborative, live and web-based training, ongoing technical assistance, a comprehensive toolkit, community linkages and other tools for facilities to improve policies and processes that impact breastfeeding outcomes.

NICHQ recently spoke with Veronica Hendrix, LVN, IBCLC, RLC, program coordinator for the Texas Ten Step Program, to get her perspective and advice for other states seeking to expand breastfeeding rates and support.

What have been the benefits of the learning collaborative?
One of the biggest benefits of the Star Achiever Learning Collaborative has been creating an environment that makes sharing easier. Hospitals are naturally competitive; they don’t typically share information with each other about their practices, good or bad. Through the in-person and virtual learning meetings, monthly conference calls, and an online collaboration tool (Yammer), the hospitals get as much access to each other as they want. They are now able to reach out to one another and “steal shamelessly/ share seamlessly,” which has become the group mantra since the beginning. Knowing they are all working together and can turn to each other to address barriers, share implementation strategies and celebrate successes has been an incredible opportunity. This is very different from what the Texas Ten Step Program can offer alone—the learning collaborative takes the potential success of these teams to the next level.

The second benefit of this collaborative has been the engagement of WIC local agency staff as they serve on hospital improvement teams. By bringing WIC and hospitals together, everyone gets to see a more complete picture of our clients’ lives and messages can be aligned across settings so they become consistent. For the first time in many areas of Texas, WIC is recognized in these hospital settings for the resources and breastfeeding knowledge they offer. This collaborative group is breaking down the silos of information that currently exist, identifying barriers and gaps, and then addressing them in ways that have never been attempted on a such broad scale in Texas. Thousands of mothers and babies across Texas will get the benefit of these two entities collaborating together. It really is an awesome partnership.

What have you learned from the experience so far?
This experience has reinforced how unique our great state of Texas is. Each of our state’s 11 public health regions is the size and population of another state, and each of these different areas of Texas have their own character, strengths and barriers. To best address the incredible immensity and diversity of our state, the faculty planning team adjusted the learning collaborative model based on the particular area that we’re working in. We don’t use a template over and over again for each cohort; we tailor and customize the experience for each cohort area.

Quality improvement (QI), and the learning collaborative model we are using, were new to me. The project has allowed me to increase my own personal knowledge of QI, which I think helps me to be a better resource for hospital staff looking for help through the Texas Ten Step Program. Tracking hospital data and learning how to us the data to move initiatives forward or build sustainability is necessary work. With many hospitals accredited through The Joint Commission now mandated to report their perinatal core measures (including exclusive breastfeeding rates), it’s timely to bring a targeted quality improvement approach to the issue of maternity practices in infant nutrition and care. Additionally, the NICHQ team has really helped with providing information that both the new learner and QI veterans alike can benefit from. They are available to teams with one click of the mouse or a quick phone call and the combined and varied experience is irreplaceable. We’re like family now—it’s been extraordinary to get to know all of faculty including NICHQ staff, physician and parent representatives.

How did you know where to start?
Julie Stagg and Tracy Erickson, our State and WIC breastfeeding coordinators began concept and capacity development for the Star Achiever Initiative in 2008, finalized the Star Achiever toolkit in 2010, and were planning details of the Star Achiever Learning Collaborative in early 2011 when I first joined the team. We divided the state into three cohorts based on their public health service region and piloted the program with Cohort A in an area of Texas where we had good breastfeeding support infrastructure and the best infant feeding outcomes. The hospitals in North Texas were most ready for implementing the Ten Steps; several were already designated through the Baby-Friendly Hospital Initiative. We opened registration to both non-designated and designated Texas Ten Step facilities as well as a few that were up for recertification through Baby-Friendly USA. Cohort A teams now serve as mentors for Cohort B. We will continue to use that model for Cohort C. In this way, everyone teaches and everyone learns, building on the knowledge of previous cohort teams.

What are some of the biggest challenges you face?
The biggest challenge for us is the dissemination of information. Collecting information via phone and email for recruitment purposes of more than 270 hospitals has been a bit of a hurdle. We’ve leaned on our relationships with the local agency WIC staff, and organizations like the Texas Collaborative for Healthy Mothers and Babies, the Texas Breastfeeding Coalition and other DSHS partners to help spread information about the good work that is happening across the state.

Keeping facilities engaged in the work can be a challenge too. There are many initiatives that hospitals are involved in and barriers exist at all levels. Whether it is staffing issues, funding, physician, patient, system or community barriers- hospitals are taxed with keeping the momentum going. We helped to address this through routine technical assistance calls with each team leader. The calls are used to identify similar themes running throughout—if similar barriers are discovered, we use the opportunity to develop a tool or provide more technical assistance to help them. A lot of the calls I make are simply to keep cheering the teams on.

What advice would you give to other programs or states considering engaging in a learning collaborative?
I recommend that other programs and states consider engaging community organizations in this work. We did this through developing Community Partner Meetings. These meetings gather community organizations from select areas that impact mothers and their families and invite them to meet and share their resources. WIC agencies serve as the host for the first meeting, and State staff provides an overview on the “State of Breastfeeding in Texas.” This presentation gives regional breastfeeding information and sets the stage for Star Achiever work using the Surgeon General’s Call to Action to Support Breastfeeding as the framework. The hope is that future meetings in these communities develop— maybe even new breastfeeding coalitions— and that the discussion will continue to expand.

Overall, my advice to others is to not get discouraged. Incremental change in maternity practices still has a significant impact and leads to more opportunities for improvement. Develop good assessment, evaluation and communication plans, connect with key partners and in the spirit of improvement, make adjustments as you go along.

What results have you seen so far?
Aggregate results from our first cohort of 20 hospitals have been impressive. In just 18 months, the overall breastfeeding rate went from a median of 84 percent to 88 percent; the percentage of mothers receiving referrals to the support they need at discharge to continue breastfeeding at home went from 49 percent to 73 percent; and the percentage of mothers that were able to raise their skin-to-skin rates after a vaginal birth went from 34 percent to 55 percent. The learning collaborative model and dedication of all the hospital teams has played such a significant factor in these results. Equally important, relationships are being built across the state. Networks of organizations are working together to move the exclusive breastfeeding needle ever closer to real improvement and the best benefit of all is that Texas mothers will be closer to reaching their personal breastfeeding goals.


To learn more about NICHQ's breastfeeding work, visit

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