Application Form

Signed Letter of Agreement

This letter affirms that ______

hospital/maternity center is committed to the achievement of a Baby-Friendly USA (BFUSA©) designation by September 1, 2017 (or within 30 months of application).

Our facility is committed to each of the following within this timeline:

  • Completion of the BFUSA© designation application by June 30, 2015 if not already completed, to enter the BFUSA© 4D pathway (
  • Payment of the fees and other related expenses as indicated on the Hospital Requirements, Benefits, and Disincentives table
  • Submission of latest Maternity Practices in Infant Nutrition and Care (mPINC) Survey Benchmark Report (2011 and/or 2013), if available
  • Compliance with the Guidelines and Evaluation Criteria for the US Baby-Friendly Hospital Initiative regarding the International Code of Marketing of Breast-milk substitutes, including the purchase of any breast milk substitutes, including special formulas and feeding supplies, at a fair market price, and by practicing in accordance with its vendor/ethics policy regarding the appropriate interaction between vendors of such items and facility staff.
  • Agreement to establish a Multi-Disciplinary Breastfeeding Team as outlined in the BFUSA© 4D Pathway including a designated Hospital Administrator and the Head of Nursing or their designee to oversee the processes to ensure achievement of the BFUSA© designation within 30 months
  • Agreement that the Hospital Executive Officer, Head of Nursing, and Heads of Departments of Obstetrics, Family Medicine, Pediatrics, Nurse Midwifery or equivalent and the Head of Nursing for Prenatal, Labor and Delivery, and Postpartum or equivalent will participate in site visit discussions and at least two EMPower webinars annually
  • Agreement to ensure that required data collection is carried out through the electronic health records (EHR) as much as possible

We understand that this application does not substitute for an application to the BFUSA© 4D Pathway. A separate but similar application must be submitted to BFUSA© upon acceptance into the EMPower initiative, if not already completed.

______

Chief Executive Officer (CEO)

______

Head of Obstetrics, Family Medicine, Pediatrics, Nurse Midwifery or Equivalent

______

Head of Nursing for Prenatal, Labor and Delivery, Postpartum or Equivalent

SECTION A: Hospital Name and Contact Information

Hospital name

Street Address /
City /
State /
Zip Code /

Name, Title, and Contact Information of Individual Submitting the Application

Applicant First Name /
Applicant Last Name /
Alternate Title /
Work Phone Number /
Email Address /

Alternate Contact Information

Applicant First Name /
Applicant Last Name /
Alternate Title /
Work Phone Number /
Email Address /

SECTION B: Hospital and Patient Population Information

2b-1. Number of live births annually at your facility:

2b-2. Distribution of Births by Race and Ethnicity

% Hispanic /
% Non-Hispanic White /
% Non-Hispanic Black /
% Non-Hispanic American Indian/Alaska Native /
% Two or more races /
% Other /

2b-3. Distribution of Births by Insurance or Payer Status (If not available, please estimate to the best of your ability)

% Private Insurance /
% Medicaid /
% Children's Health Insurance Program (CHIP) /
% Self Pay /
% Other /

2b-4. Co-Administration of Facilities. (Please Circle Yes or No for each of the following questions).

Is your hospital part of a healthcare system? / / Yes
/ No
Is another hospital within your system applying to this initiative? / / Yes
/ No
/ Don't know
Has another hospital within your system achieved Baby-Friendly designation? / / Yes
/ No
/ Don't know

Please list the name and location of other hospitals within your system that may be applying to be part of this initiative or that have achieved Baby-Friendly designation:

Name of Hospital 1 /
Location of Hospital 1 /
Please check if currently Baby-Friendly designated. /
Name of Hospital 2 /
Location of Hospital 2 /
Please check if currently Baby-Friendly designated. /
/ Add additional hospitals?
Name of Hospital 3 /
Location of Hospital 3 /
Please check if currently Baby-Friendly designated. /
Name of Hospital 4 /
Location of Hospital 4 /
Please check if currently Baby-Friendly designated. /
Name of Hospital 5 /
Location of Hospital 5 /
Please check if currently Baby-Friendly designated. /
Name of Hospital 6 /
Location of Hospital 6 /
Please check if currently Baby-Friendly designated. /

SECTION C: Interest/Experience in Baby-Friendly Designation

2c-1. Briefly describe why your facility, including your hospital leadership, is interested in participating in the EMPower Breastfeeding initiative including details on how this effort aligns with your facility’s vision, mission, strategic plan, and/or priorities. (Please note 300 word maximum.)

2c-2. Competing priorities are very common during change efforts. Please describe any of the competing priorities (things like EHR implementation, construction or relocation, change in hospital ownership/affiliation, etc.) you anticipate within your facility, and how your facility and hospital leadership will mitigate them. (Please note 300 word maximum.)

2c-3. Briefly describe any previous experience your newborn/L&D; settings have had with quality improvement and/or change initiatives including the quality improvement methods/model(s) used and what your team learned from the initiative(s). (Please note 300 word maximum and no more than 3 examples.)

2c-4. Please provide a description of hospital senior leadership who will be involved in the initiative, including their role and their ability to affect change within your facility. Also, note any recent or anticipated changes in key leadership that could affect your initiative (Please note 250 word maximum.)

2c-5. Please provide a description of how your facility plans to staff the Multi-disciplinary Breastfeeding Team required to participate in EMPower and achieve BFUSA© designation. We suggest considering a comprehensive team with strong leadership skills that is representative of all groups serving the mother-baby dyad including community representation. If your hospital has already established a multi-disciplinary team, describe the roles of members and other individuals your hospital may include in this process. Please list existing hospital committees that you will include in this work. (Please note 200 word maximum.)

2c-6. Has your facility has initiated the BFUSA© 4D Pathway?

/ Yes
/ No

Please a) indicate a timeline of past progress, including which phase and duration of the 4D pathway b) describe the challenges encountered, and c) describe how participation in this project will help you achieve Baby-Friendly designation. If your facility has not initiated the 4D pathway, please indicate “Not Applicable”. (Please note 250 word maximum.)

2c-7. Has your hospital applied for or has your hospital been accepted into another project related to implementing the Ten Steps to Successful Breastfeeding and/ or achieving Baby-Friendly designation, including any participation in state level recognition programs?

/ Yes
/ No

Please name the project and the date you were accepted or started the project. (Please note 100 word maximum.)

2c-8. Please provide detail on your facility’s ability to routinely collect data on early, exclusive breastfeeding and on additional maternity practices noted in the BFUSA© Self-Appraisal.

Does your facility have an EHR system in use? / / Yes
/ No
Does your current EHR system allow collection of data as indicated in the US Breastfeeding Committee’s EHR Best Practices guide listed here? / / Yes
/ No
Are you willing to adapt your system to collect these data? / / Yes
/ No

Please use the space below to provide additional detail, if needed.

Does your facility have available your score from either the 2011 or 2013 Maternity Practices in Infant Nutrition and Care (mPINC) Survey report?

/ Yes
/ No

Please provide detail on the total and each subsection of the score below.

2011 / 2013
Labor & delivery / /
Feeding of breastfed infant / /
Breastfeeding assistance / /
Mother/infant contact / /
Discharge care / /
Staff training / /
Structural & Organizational Aspects / /
Composite Quality Practice Score / /

Thank You

This concludes the online portion of this application.