Mandates, Metrics, Mothers, Meals

She was polite and soft-spoken. With our interpreter, we explained why her 3-week-old infant would need to stay in the hospital, focusing on the medical care we would be providing. The mother was alone and hours away from her family, her support. The language barrier only added to her isolation.

The infant improved quickly and continued to have good breastfeeding sessions with the expected daily weight gain. Days into the hospitalization, we met a family friend on rounds. He lived locally and had brought food to the mother. Despite our consistent use of an interpreter, we never inquired as to the mother’s nutrition, focusing only on the infant and praising her for breastfeeding.

Our hospital policy provides a meal tray for all breastfeeding mothers, but the system requires an electronic order in the patient’s chart for this meal to be delivered. Upon review of active orders, we realized that no lactation tray was ordered for our patient’s mother. We quickly fixed our error, acknowledging Alexander Pope’s wisdom in the phrase “to err is human” and immediately entered a lactation tray order for all subsequent meals.

Shock. Embarrassment. How was it that a mother desperately trying to breastfeed was not receiving this basic service? How often have we counseled breastfeeding mothers on the importance of their nutrition given the significant energy expenditure required to make breast milk? What if we channeled our frustration toward what felt like an immense injustice to right a systematic wrong?

Most residency programs mandate some form of quality improvement (QI) project prior to graduation. For the overwhelmed trainee, picking the path of least resistance is tempting. This often manifests as joining a well-established behemoth of a project—an efficient machine that takes in residents and spits out checked boxes without requiring much from the resident.

With a small, efficient, and emotionally invested team, we took the road less traveled. We channeled our passion and created our own QI project with a global aim of improving the percentage of lactation trays ordered for our breastfeeding mothers at the time of admission. This project both would check the Accreditation Council for Graduate Medical Education box and, more importantly, positively impact the mothers of our patients.

Creating and owning a small project taught us the core concepts of QI. As frontline providers, we see our flawed health care system daily, but now we have the QI toolkit to address these challenges. We know how to define the problem, determine how we will measure it (metrics), and track our data over time looking for systematic improvement.

But interventions need to be easy; doing the right thing should be the default. Minimize omission. Simply by working with our information technology department, we linked the breast milk diet order to a meal tray for the mother. A simple solution with sustainable results.

In providing nourishment to our breastfeeding mothers, we in turn nourished a deeper appreciation for the process behind this checkbox requirement. And further still, we gained an understanding as to why it is part of graduate medical education.

This was not groundbreaking QI research, nor did we send shock waves through the medical community.

But this mother did not need groundbreaking research or shockwaves. She needed breakfast.