Going “Baby-Friendly” with COPE Health Solutions

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The Problem

California law (Health and Safety Code Section 123367) requires all hospitals providing perinatal services to implement a maternity-focused program in line with the United Nations International Children’s Emergency Fund’s (UNICEF) “Ten Steps to Effective Breastfeeding” through the Baby-Friendly Hospital Initiative (BFHI) or a comparable process by January 1, 2025. Currently, less than one in five qualifying hospitals in California meet this requirement.

The BFHI aims to improve maternity care by emphasizing the benefits of breastfeeding for child development and by promoting mother/baby bonding experiences. In addition to audits on breastfeeding techniques and mother-baby interaction, the designation method required by Baby-Friendly USA (BFUSA) involves a prescriptive regimen of staff and patient education.

Through a $500,000 grant provided by First 5 LA, St. Francis Medical Center (SFMC) in Lynwood began its Baby-Friendly journey in October 2011. The hospital was faced with the task of launching the project, building the communication strategy and auditing the entire hospital staff and perinatal patient population. Sylvia Bavarsad, RNC, BSN, IBCLC, Women’s Health Center/Maternity Clinical Educator and Lactation Consultant, the hospital manager tasked with implementing this program, recognized that staffing constraints and workload volumes would be a barrier to successful implementation and compliance with the law. Due to limited resources, Sylvia was the only full time employee designated by SFMC to implement the BFHI project, along with intermittent support from two part-time hospital employees.

The Solution

SFMC has been home to the COPE Health Solutions Clinical Care Extender (CCE) Program and PrepStep-RN Program since October 2009, a partnership which provides over 425 active participants to support the hospital’s clinical and administrative workforce. The hospital leveraged this resource to supply the extra hands needed to drive the project forward.

BFHI uses the “4-D Pathway” implementation model for hospital accreditation. D1 – Discovery includes establishing executive support and completing a self-assessment. At SFMC, D2 – Development was challenged from the onset due to the lack of a necessary task force for the initiative – the hospital could only provide one employee. This stage also requires the curriculum and materials for hospital-wide trainings to be developed. D3 – Dissemination requires educating and training the entire nursing staff and patient population.

A partnership between SFMC’s BFHI and the COPE Health Solutions’ programs was the best-fit solution for an initiative faced with personnel needs. A team of eight CCEs and two PrepStep-RNs was assembled in order to complete the extensive amount of auditing required – a crucial element for the success of the Dissemination and Development phases. The team then received a four-hour training on the Baby Friendly process from Sylvia Bavarsad. Post training, each CCE provided four hours of assistance per week while the PrepStep-RNs provided 12 hours of assistance per week.

In addition to completing audits, CCEs and PrepStep-RNs also assisted with the creation of educational materials for staff and patients. The leadership and organized structure of the CCE and PrepStep-RN programs gave the BFHI at SFMC operational support, which enabled the BFHI to progress at an accelerated pace.


The use of CCEs and PrepStep-RNs facilitated the hospital in achieving its goal as follows:

  • From December 2012 to December 2013, the CCEs and PrepStep-RNs of SFMC completed 100% of audits required for the D3 phase of the BFHI.
  • Over the last 26 months, the CCE program and the PrepStep-RN program provided the BFHI at SFMC with 1851 hours of support.
  • The leadership of the CCE program assisted in the development of over 10 educational documents to be used in staff and patient education. Examples include postpartum staff booklets and breastfeeding charts to be placed in new mother patient rooms.

SFMC is currently in phase D4 – Designation, expecting to receive auditors from the organization in September 2014. In three years’ time, with only one full-time staff member allocated, SFMC now looks forward to achieving a coveted designation, making it legally viable as a perinatal facility in the future. Furthermore, SFMC will be the first institution to do so using the resources of the CCE and PrepStep-RN programs, effectively leveraging the programs to improve the implementation efficiency of a hospital-wide initiative.

For more information, please contact:
Poornima Bajwa
Manager, Health Care Talent Innovations

Sylvia Bavarsad
SFMC BFHI Project Manager