Maintaining Designation

Maintaining Designation2018-10-16T15:22:38+00:00

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Sustainability

Achieving Baby-Friendly designation is an important part of the journey…but it is not the end point. Routine data collection, monitoring of practices and quality improvement activities are vital to ensuring that the Baby-Friendly standards are maintained. Facilities are responsible for ongoing adherence to the most current Guidelines and Evaluation Criteria (GEC).

Baby-Friendly designation is conferred for a 5 year period. The 1st, 2nd and 3rd years post-designation are the Annual Quality Improvement (AQI) Phase. The 4th and 5th years post-designation are the Re-Designation Phase. The 4th year is referred to as “Re-Designation – Year 1” and the 5th year is referred to as “Re-Designation – Year 2.”

Pathway to Baby-Friendly Designation - Sustainability

Annual Quality Improvement (AQI)

To assist facilities with maintaining compliance with the most current Guidelines and Evaluation Criteria, all Baby-Friendly designated facilities are required to complete the assigned AQI activities. It is easier to maintain a practice than to fix one that has backslid. It is important for facilities to maintain their multi-disciplinary team to help review audit results and determine the appropriate quality improvement activities.

This should minimally be convened on a quarterly basis.

The multidisciplinary committee assembled to conduct the necessary work for the facility to achieve designation remains important in the post designation period.  Its membership should be reviewed periodically to ensure the necessary departments and skills are represented. A key function of this committee is to conduct audits, review results and implement appropriate quality improvement activities.

This should be completed by March of each year.

BFUSA posts annual instructions to the AQI phase in the portal.  These instructions inform facilities of the required submissions, specific practices to be audited, due dates and fees. (Click here for the most current fee schedule.)

Fair Market Price Code Compliance Verification Form (FMP Form)

  • Annual review of the FMP Forms are required to monitor the compliance with the International Code of Marketing of Breast-milk Substitutes.

Facility Data Sheet (FDS)

  • Annual updating of the FDS is required to capture up-to-date data on the facility to capture any changes in birth rates, prenatal affiliations, breastfeeding rates, and sample sizes for the required audits.

Data collection and evaluation are the foundation of a robust quality improvement program. Facilities in the AQI phase must audit assigned steps using the BFUSA audit tools and submit their results to Baby-Friendly USA. The goal is for facilities to determine if they are still in compliance with the most current Guidelines and Evaluation Criteria for the areas under review. If the audits reveal issues, the facility multidisciplinary team must design a quality improvement plan to address the areas of concern. This process is critical to the successful sustainability of the practices outlined in the Guidelines and Evaluation Criteria.

For audit results out of compliance:

If the audit results reveal that practices have slipped, quality improvement plans are required to be submitted for each area out of compliance. Re-submission of audits showing compliance is also required.

Re-Designation (Re-Des)

Re-Designation is a two year process and is ultimately conferred through an on-site assessment. Re-Designation “classes” are defined by the year the designation expires (for example, a facility designated from 2013-2018 is in the 2018 Re-Designation “class”). Facilities in the Re-Designation process are provided with an annual on-line toolkit which is made available once they are invoiced for the annual phase fee.

FIRST YEAR (referred to as “Re-Designation Year 1”)

This should minimally be convened on a quarterly basis.

The multidisciplinary committee assembled to conduct the necessary work for the facility to achieve designation is equally important for the re-designation process.  During the Re-Designation Process, this committee will review the most current Guidelines and Evaluation Criteria and conduct a variety of activities to ensure the facility is in compliance.

Regular meetings and auditing of practices provides the opportunity for facility-wide awareness of the importance of the practices and activities underway to address areas of slippage. Sharing the work allows your multi-disciplinary committee to make progress in multiple areas at once.

This should be completed in January of Re-Designation Year 1.

BFUSA posts annual instructions to the Re-Designation phase portal. These instructions inform facilities of the required submissions, specific practices to be audited, due dates and fees.  (Click here for the most current fee schedule.)

A fundamental premise of the BFHI is that the hospital policy drives practice.  Step 1 of the Ten Steps to Successful Breastfeeding requires the development of a comprehensive infant feeding policy that establishes breastfeeding as the norm and describes how the remaining steps will be practiced at the facility.

Prior to their initial designation, facilities developed an infant feeding policy that met the BFHI requirements in place at that time.  Policies should be periodically reviewed and updated to reflect current evidence and standards.

Fair Market Price Code Compliance Verification Form (FMP Form)

  • Annual review of the FMP Forms are required to monitor the compliance with the International Code of Marketing of Breast-milk Substitutes.

Facility Data Sheet (FDS)

  • Annual updating of the FDS is required to capture up-to-date data on the facility to capture any changes in birth rates, prenatal affiliations, breastfeeding rates, and sample sizes for the required audits.

Business Associate Agreement (BAA)

Data collection and evaluation are the foundation of a robust quality improvement program. Facilities in the AQI phase must audit assigned steps using the BFUSA audit tools and submit their results to Baby-Friendly USA. The goal is for facilities to determine if they are still in compliance with the Guidelines and Evaluation Criteria for the areas under review. If the audits reveal issues, the facility multidisciplinary team must design a quality improvement plan to address the areas of concern. This process is critical to the successful sustainability of the practices outlined in the Guidelines and Evaluation Criteria.

BFUSA provides facilities with a Readiness Assessment Interview in the 4th year post-designation. This 90-minute phone interview conducted by BFUSA staff consists of a series of questions intended to assess a facility’s readiness for the on-site assessment. During the interview, we will discuss the quality improvement audits, infant feeding policy, and Fair Market Price Code Compliance Verification Form. BFUSA will provide verbal and written feedback on areas in need of improvement. Facilities find that the Readiness Assessment Interview helps them identify areas that require additional attention prior to the on-site assessment being scheduled.

SECOND YEAR (referred to as “Re-Designation Year 2”)

This should be completed in January of Re-Designation Year 2.

BFUSA posts annual instructions to the Re-Designation phase portal. These instructions inform facilities of the required submissions, specific practices to be audited, due dates and fees.  (Click here for the most current fee schedule.)

The need for practice improvement will be identified in two specific ways; audit results and written feedback from the Readiness Assessment Interview (RAI).  The multidisciplinary committee should review this information and decide on the best course of action to make the necessary improvements.

Submitted within 2 weeks of the RAI.

The template letter of invitation provided by BFUSA must be submitted on facility letterhead within 2 weeks of the RAI call in order to schedule the On-site Assessment. Facilities receive an offer of assessment dates within a few weeks of submitting their letter, as long as their Business Associate Agreement is executed.

After facilities submit their letter of invitation they spend the time completing any follow-up necessary based on feedback received on the RAI, as well as reviewing the On-Site Assessment Checklist located in the portal to ensure necessary items are available for assessment.

The on-site assessment is a two-stage process. The first is the on-site assessment conducted by a BFUSA assessment team. Upon completion of their visit, the findings are compiled into a report, blinded and sent to the BFUSA External Review Board (ERB). The ERB determines whether or not the facility has fully implemented the Guidelines and Evaluation Criteria. Upon determination that the Guidelines and Evaluation Criteria have been met, the facility will officially be designated and granted a license to use the Baby-Friendly certification mark. If the facility does not pass the on-site assessment, there is a corrective action process that may require a quality improvement project or re-assessment to demonstrate identified problems have been corrected.