NY Hospital Sees Breastfeeding Rates Soar with Neonatologist Leading Change

5 Ways a Physician QI Team Leader Helps Foster Change More Quickly

When Juliana Oppong delivered her baby, she didn’t have time to think about breastfeeding. Born very premature, Juliana’s daughter spent more than a month in the neonatal intensive care unit (NICU). Too young to properly latch, Juliana thought formula was the only option—until she talked to Diana Lagardi, RN, her nurse.

“She told me the benefits of a mother’s milk, especially for a preemie,” Oppong says. “Even though it meant pumping until my baby was old enough to latch, I wanted what was best.”

While Juliana didn’t know it at the time, that conversation was the result of a cascade of events that began months earlier at New York’s Montefiore New Rochelle Hospital. It all started with Yogangi Malhotra, MD, attending neonatologist and an early champion of breastfeeding, who was committed to improving Montefiore’s exclusive breastfeeding rates.

Malhotra, with the administration’s support, sought out participation in the NICHQ-led New York State Breastfeeding Quality Improvement in Hospitals (NYS BQIH) Learning Collaborative. When the project launched in April 2014, Montefiore’s exclusive breastfeeding rates for mothers during their hospital stay hovered at just 4 percent—a number that has since jumped to 52 percent.

“Seeing everyone’s excitement about this initiative is one of the most rewarding aspects. Everyone takes such pride in it,” Malhotra says. “Despite the growing pains and initial resistance, you have to get to that place where it truly seems like people trust you and believe that you are on their side. That was key—being a good listener and really understanding everyone’s perspective.”

Malhotra knew it wouldn’t be easy to bring change to any hospital, but says her unique role as a neonatologist and the QI project team leader helped foster change more quickly in five key areas.

Building consensus

When Malhotra began the road to improving breastfeeding rates, she knew that commitment would be crucial to success, particularly from the senior leadership team. “I think it’s much easier for a physician to go to the CEO or a senior administrator and say, ‘this is important,’” she says.

After meeting with Anthony Alfano, the CEO, and other members of the administration and discussing system changes that would encourage breastfeeding by new mothers, Malhotra began building her team. In a small community hospital, it was all hands on deck. From WIC peer counselors to physicians and unit clerks, Malhotra knew that she needed the utmost commitment from everyone.

“The nurses are truly the driving force,” Malhotra says. “They really believed in it. I was just the cheerleader. They were in the trenches, talking to moms in the middle of the night when they were frustrated and tired and asking for formula.”

Becoming a convener

When BQIH first started, Malhotra says she was constantly on the floors, talking and listening to the nurses and making sure everyone was talking about breastfeeding all the time so that no one forgot about it. Once a week, she met informally with champion nurses, mainly catching them in the hallway between patients and asking what was working and what wasn’t. It became a way to monitor and measure the team’s success.

Malhotra also instituted “Mother’s Milk—The Gold Standard Meetings,” a once-a-month event with lunch included, where all clinicians were invited to talk about the benefits of breastfeeding. It marked the early days of what eventually became the hospital’s breastfeeding committee. Now the meetings are used for BQIH strategic planning, administrative issues, action items and to ensure accountability. The total membership of the committee is fluid and open to all, with a small core group. This allows for the work to go on when individual members are pulled away for other obligations.

Educating peer-to-peer

During Montefiore New Rochelle’s early days with the collaborative, Malhotra noticed a gap between physicians’ beliefs about breastfeeding and evidence. Malhotra recalls one obstetrician telling her that she was concerned that the babies weren’t getting enough milk in the first few days of breastfeeding and its harmful effects. Malhotra was able to talk with her about the studies done around this and learn more about her own experiences that contributed to her thinking. In the end the doctor was reassured and became a great supporter. She has since completed the hospital’s breastfeeding education course.

Nothing matches one-on-one education, says Malhotra. She began leading Friday morning updates over cranberry rolls where doctors and nurses could stop by between shift changes. They talked about successes, challenges, lessons learned, documentation or testing a new change. It became a safe place to ask questions and quickly became a popular meeting.

“At one point they would be waiting for me before I even arrived,” Malhotra says. “They were all thirsting for knowledge and discussion.”

Reassuring patients

For Oppong, a long stay in the NICU created many concerns, particularly around nutrition.

“I kept thinking, is the baby getting anything? I kept pumping and pumping but it didn’t seem like anything was coming out,” she says. “Having my baby’s doctor explain that she was okay and better understanding the importance of colostrum really helped me persevere.”

Malhotra says that Oppong’s question is a common one. “Explaining what is normal and setting the expectation goes a long way when it comes from a physician, particularly when we say it is what’s best for the baby.” Our WIC peer counselors have played a crucial role in this. They round on our patients six days a week, providing them with assistance and reassurance.

Making the process transparent

Committed to sharing information, Malhotra and the breastfeeding committee instituted a “Golden Colostrum Box” in the staff lounge. All staff members are encouraged to write down their successful and unsuccessful stories related to the initiative. Monthly winners receive a Starbucks gift card, and some notoriety. Their photo is blown-up and posted on a bulletin board, alongside their winning entry.

“These are our champions,” Malhotra says. “It sparks excitement and helps us get everyone talking and engaged.”

The hospital’s BQIH graphs are also posted prominently so that staff can see how the hospital is progressing. “As soon as you arrive on the maternity unit, you see the cheerful posters about this initiative throughout the halls—and they are all in the classic golden colostrum color,” says Malhotra.

Montefiore New Rochelle was also recognized by the Mayor of New Rochelle in November 2014 for its efforts to protect, promote and support breastfeeding.

As for Oppong, she left the hospital as a breastfeeding mom and became an enthusiastic advocate for other patients, particularly for those with babies in the NICU. She joined Montefiore’s collaborative team as a parent partner, and more recently, became a peer counselor through the hospital’s WIC program.