The quality improvement project aims to reduce the use of formula feeding from 80% to 50% for neonates admitted to the NICU at Shree Birendra Hospital over 4 weeks. The team identified the growing use of formula feeding over mother's own milk as the key problem. They analyzed the root causes using tools like fishbone diagram and 5 whys. Key causes identified included lack of breastfeeding knowledge, non-compliance with protocols, and inadequate support for mothers. The team will test providing breastfeeding education and access to breast pumps. They will measure the percentage of neonates receiving mother's own milk weekly to assess the impact of these changes. The goal is to sustain improvements by establishing supportive policies and ongoing staff training.

2. Quality Improvement
Facility Name: -Shree Birendra Hospital
Members preparing the
Project Template
1. Dr. Moon Thapa
2. Dr Bishwo Raj Bahadur Kunwar
3. ON Sunita Shrestha

3. Step 1: Identifying a problem, forming a
team and writing an aim statement
• Problem identified – There is a growing concern regarding the
readiness and ability of neonates for enteral nutrition. Many
neonates facing the challenges such as feeding intolerance and
higher risk of Necrotizing Enterocolitis when attempting to switch to
formula feeding. Also the formula feeding practice in the ward is
growing day to day covering approximately 80% of the neonates
admitted in NICU.

4. QI Team members and designation
S.N Name Team roles
1 Col Dr. Moon Thapa Team leader
2 Maj. Dr. Bishwo Raj Bdr Kunwar Counseller
3 Dr. Anil Pandey Counsellor
4 Dr. Ayushi Sitaula Communicator
5 ON Samita Karki Data collector
6 ON Sunita Shrestha Data collector
7 T/Sub Geeta Byanjankar Observer
8 T/Sub Sandhya Wagle Recorder
9 T/Sgt Junga Bdr Kunwar Observer

5. Date of team first meeting
• 2080/05/19

6. Aim Statement
•We aim to reduce use of formula feed by
Mother’s Own Milk (MOM)from 80% to
50% in neonates admitted in NICU within 4
weeks .

7. Step 2: Analyzing and measuring quality of care
The analysis tool you can
use
What do you want to learn from using the
tool?
-Fishbone
-Five Why's
-Pareto principle
-Process flowchart
-
-
-

8. What do you want to learn from using the
tool?
• Understanding the motivation and reasons why formula feed is
preferred over moms own milk.
• Root cause analysis to identify the fundamental factors contributing
the usage of formula feed
• Prioritizing causes to understand which factors are more critical in
contributing the causes
• Facilitate problem solving by developing effective solutions and
strategies to identified root cause.
• Promote continuous improvement

9. Root cause analysis
Reduced
usage of
MOM
Environment
● Training
deficiencies
● Fatigue and stress
● Staffing shortages
● Formula feed are being
sold at hospital
premises.
● No any policies related
to exclusive
breastfeeding.
● Inconsistent
enforcement
● Baby has poor
sucking reflex
● Health conditions
● Developmental
issues
● Allergies or
sensitivities
● fatigue and
restlessness
● lack of knowledge
● Inexperienced mothers
● engorged breast
● Communication gaps
● Maternal health impact
● Cultural or personal
preferences
● no privacy
● lack of support from family
member
● stressful environment of
nicu
● Inadequate facilities
-
● Non-compliance with
protocols
● Poor documentation
Procedure
Mother
Personnel Policy
Baby related

10. Step 2: Analyzing and measuring quality of care
What measure will you
use?
- To assess the success of our quality
improvement efforts, we will measure the
percentage of neonates feeding Moms Own Milk
and compare it to the data we collected before.
-
Is this a process or outcome
measure?
It is an outcome measure as we are actually measuring the actual
outcome of neonates using MOM.
Numerator
Neonates feeding Moms Own Milk
Denominator
Total number of neonates admitted in NICU in four weeks.
What data sources will you
use?
To collect data we will rely on patient records, surveys of mothers and
interviews.
How frequently will you
review data?
weekly
Who will be responsible?
A dedicated team of health care providers including doctors, nurses,

11. Step 3: Developing and testing changes
What changes do you think
will help solve the problem?
How will this change improve care?
1. Breastfeeding education -
2. Breastfeeding friendly
environment
-
3. Offering lactation support
(plenty of sleep, encouraging for a
healthy diet, breast pump for
expressing the milk )
-
4.Addressing potential barriers to
breastfeeding
-

12. Step 3: Developing and testing changes
WHAT change will you test?
-breastfeeding education initially and Usage of electric breast
pump .
WHO will make the change? (if this person is not on the QI team he/she
should be added)
- Team members in QI project
WHERE will they test the change?
- We implemented the programs in NICU ward
WHEN will the test be done & for HOW LONG?
- The test started on 2080/05/19 lasting till four weeks
What do you want to LEARN from this test?
- The primary goal of the test is to determine if the test helped in the
increment usage of MOM
What will you MEASURE?
- Changes in the percentage of neonates feeding MOM after
implementation of the programs.
What do you PREDICT will happen? (what do you expect) - We anticipate an increase in usage of MOM as a result .
PLA
N a
TES
T
Do
Study
Act

13. Step 4: Sustaining improvement
Describe some actions you can take at your facility to sustain
quality improvement
- Establish breastfeeding policies and guidelines that support and promote
breastfeeding within the healthcare facility.
- Providing continuous staff training on the latest breastfeeding techniques
and guidelines
-regularly collecting and analyzing the data to identify any emerging issues
and addressing them promptly.