Information About Operating Structure

The structure and services of a health care institution impact the work leading up to, and including, the assessment of that facility for compliance with the BFUSA’s Guidelines and Evaluation Criteria (GEC). It is essential that facilities provide BFUSA the most current and accurate information about their operational structure in a timely manner. This should include information on all of the services provided, either directly or indirectly, through contract and/or through “affiliation” that relate to the implementation of the GEC.

Single Campus Enrollment

In recognition of the dynamic state of health care in the United States and the understanding that clinical practice and outcomes may vary from hospital campus to hospital campus, BFUSA has instituted a policy that requires each campus of a multi-campus health care institution to be separately accredited.

Each individual campus must:

  • Register with BFUSA.
  • Assign its own USERS. (Each facility must provide a minimum of two and a maximum of three USERS.)  PLEASE NOTE: The same USER and/or USER email cannot be assigned to more than one role at the same campus. The same USER and/or USER email cannot be assigned to more than one campus.
  • Pay all fees and complete all 4-D Pathway requirements.
  • Identify all of its affiliated prenatal services. (Information can be accessed in the BFUSA portal by any of the registered primary, secondary, or alternate USERs.)
  • Undergo the on-site assessment.

Campus means the institution’s main buildings and the physical area immediately adjacent to them, other areas and structures that are not strictly contiguous to the main buildings but are located on the same property or within 250 yards of the main buildings, and any other areas determined, on an individual case basis, to be part of the provider’s campus.

Notification to BFUSA of Changes to Facility Structure and Services

Facilities are responsible for notifying BFUSA of all significant changes that impact their implementation of the US Baby-Friendly Guidelines and Evaluation Criteria (GEC) within 90 days of their occurrence. Significant changes include, but are not limited, to those listed below.

User and Leadership Changes

USERS – If the change relates to the facility’s Primary, Secondary or Alternate USER, a “USER Change Form” must be completed, signed by the Director of Maternity and submitted to BFUSA to remove old staff access to the portal and assign new passwords for the new staff that should have access to the portal.  The “USER Change Form” can be accessed in the portal by any of the registered USERs (primary, secondary or alternate).

Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO) and/or Director of Maternity – The facility’s Primary USER must update the Facility Details page with new contact information in the Baby-Friendly USA portal when any of these leadership positions have changed.

Ownership Changes

FACILITIES WORKING TOWARDS DESIGNATION – The new owner must sign and submit the CEO Support and Primary User Letter of Intent signifying the facility’s intent to continue to pursue Baby-Friendly designation.

DESIGNATED FACILITIES – The new owner must send BFUSA a signed letter on facility letterhead reporting the new ownership.  The letter must state either:

  • The facility’s current implementation of the GEC will not be impacted and why, or
  • The facility’s current implementation of the GEC will be impacted and what plans the facility has to insure that all requirements will continue to be met.

The facility must complete and submit the BFUSA “Facility Changes Form.” The form can be accessed in the portal by any of the registered USERs (primary, secondary or alternate).

Facility Mergers, Physical Moves, Mailing Address Changes, Email Domain Changes, and/or Changes in the Configuration of Premises

The facility must send a letter, on facility letterhead, signed by the CEO, CMO or CNO describing the changes.  The letter must state either:

  • The facility’s current implementation of the GEC will not be impacted and why, or
  • The facility’s current implementation of the GEC will be impacted and what plans the facility has to insure that all requirements will continue to be met.

The facility must complete and submit the BFUSA “Facility Changes Form.” The form can be accessed in the portal by any of the registered USERs (primary, secondary or alternate).

In addition, if the merger results in more than one campus providing birthing services, only the campus that is registered with BFUSA and has undergone an on-site assessment may claim Baby-Friendly designation.   In order for the new campus to claim Baby-Friendly designation, its leadership must register with BFUSA, go through the 4-D Pathway and undergo an on-site assessment.

IMPORTANT NOTE:  When there are any significant changes at a facility, BFUSA may request further information and/or an on-site assessment to ensure that a designated facility is in line with the GEC.