Step-by-step framework – NICU QI Tools

This NICU lactation Quality Improvement (QI) toolkit is a step-by-step pathway to support high dose, long exposure of own mother’s milk for all infants, which describes

  • What NICU lactation QI is
  • Why NICU lactation QI is such a valuable approach.

How to get the project off the ground.

Teacher explaining step-by-step framework to students and nurses

What is NICU lactation quality improvement?

NICU lactation QI is used to systematically improve lactation care and infant health outcomes through evidence-based best practices.

QI is a simple way to test pre and post intervention with data collection, monitoring and evaluation to adopt, adapt or abandon practice changes in lactation care.

QI is a continuous process, and planning sustainability of practice change needs to be integrated from the beginning of the project.

Why is NICU lactation quality improvement important?

Strong breastfeeding support programmes for at-breast feeding exist with global standardised metrics for the healthy-mother, healthy-baby dyad:1

  • Breastfeeding within 1 hour of birth
  • Exclusive breastfeeding at 6 months

However, these metrics are not applicable to the vulnerable NICU mother and infant population.

NICU lactation QI is a framework used to systematically improve lactation care and vulnerable infant health outcomes through evidence-based best practices.

How to implement NICU lactation QI

  1. Preparing and planning the QI project
  2. Measuring lactation care interventions
  3. Monitoring and evaluation
  4. Making NICU lactation QI sustainable

Step 1:Preparing and planning the QI project

Establishing a working group

Establishing a working group, provides a collaborative approach to guide and steer the QI project through planning, intervention, reviewing and implementing practice change.

The QI working group is responsible for:

  • Planning and engaging with stakeholders
  • Defining NICU lactation QI project goals and strategy
  • Driving the QI project
  • Keeping QI on track
  • Maintaining momentum and ownership
  • Driving organisational commitment

The group is responsible for reviewing the data, identifying areas to focus on and making recommendations for practice change implementation to meet project goals.

It is valuable to partner with the ‘right’ people to advocate for the most vulnerable infants receiving high dose, long exposure to own mother’s milk (OMM) and to integrate effective lactation interventions into day-to-day practices.

  • Neonatologist, Advanced nurse practitioner
  • Head of midwifery and neonatal services (inclusive of obstetric theatre)
  • NICU/ maternity clinical educators
  • Nurse/ midwife representation from NICU
  • Nurse/ midwife representation from delivery suite
  • Nurse/ midwife representation from maternity ward
  • Lactation consultant or Infant feeding lead
  • Data assistant who will collect data

Analysing the current situation

The interactive NICU scorecard is a tool that can assist you to self-evaluate your department lactation practices. When embarking on QI within multiple clinical areas such as NICU, maternity and delivery departments it may be that the areas that are working well, along with gaps, challenges and barriers differ between the clinical areas.

Step 2: Measuring lactation care interventions

Without data you’re just another person with an opinion”

Why collect data?

  • Draws attention to challenges
  • Makes gaps/ deficit clearly visible
  • Provides quantifiable evidence
  • Motivates action
  • Creates momentum and enthusiasm

What to measure?

It is important to measure the right thing. NICU QI in lactation care focuses on quantifiable data :

Counting the number of

  • frequent expressions
  • mothers fully informed

Tracking time to

  • first expression
  • to milk coming in

Measuring the proportion (%) of

  • feed composition OMM:DHM:Formula
  • infants achieving >50 ml/kg/day
  • exclusive breastfeeding at and after NICU discharge

It is important to factor in the time needed to extract data from the records and input data to the collection database.

Collecting continuous data

  • provides a series of data points over time
  • brings about a story / journey in the data
  • allows change to be detected as it occurs

Measuring baseline

Collecting data prospectively provides a real-time reflection. It is critical to have data from before the intervention to visualise whether the intervention has led to any changes.

The baseline cohort is the ‘control’ and needs to provide real-time patient insight before the intervention. The working group can establish the size and timeline of the baseline cohort and decide if specific patient groups, such as infants under 1500gms / less than 32 weeks will be analysed. The data collection tool supports group selective data for analytics.

Implementing change

Implementing practice change to improve outcomes requires collaborative working with all maternity services and NICU.

Targeted education and training to all HCPs that engage and support mothers and families of NICU infants is important to ensure that consistent information is given to mothers. Recurrent training is required to improve and sustain best practices.

Step 3: Monitoring and evaluation

QI is not a one-time intervention as a research project is. QI is a process of continuously monitoring, evaluating, adopting, adapting or abandoning the practice changes.

Regular review of the data is critical to:

  • Ensure correct data is collected, identify what is missing and adopt correct data capture
  • Have a real-time review of the current situation
  • Identify gaps
  • Implement additional education
  • Discuss as a working group what is going well, what needs to be focused on next, and who will be responsible

Compare progress made to baseline and previous month.

Step 4: Making NICU lactation QI sustainable

QI is a continuous process, and planning sustainability of the practice change needs to be integrated from the beginning.

It takes time for new interventions to be embedded into standardised daily practices. Regular collection of lactation and infant feeding data provides opportunities to monitor and evaluate practice and lactation outcomes and to sustain and evolve quality of care.

Integrating a regular lactation training programme enables HCPs to deliver and support consistent lactation information and practices to at-risk and NICU mothers prenatally.


1 UNICEF, WHO. Protecting, promoting and supporting breastfeeding: The baby-friendly hospital initiative for small, sick and preterm newborns. Geneva, New York: WHO; UNICEF; 2020. 42 p.