How to Apply

First Step- Form a Task Force

Making the decision to improve practices, develop and enact policy, and create systems-wide change can be a bit overwhelming. Every facility has different levels of readiness and potential obstacles. Development of a multi-disciplinary task force to begin the application and review the current state of a facility’s policy and practice related to breastfeeding is a model way to address the various components of the TTS application. This task force can be expanded in the future to accomplish other facility goals and can seamlessly move into the task force recommended by Baby Friendly for the BFHI designation.

Recommended task force members include:

  • Hospital CEO/ Administration
  • Lactation Specialist
  • Nurse Managers
  • Physicians (OB, Pediatric, Neonatology)
  • Nursing staff (day/night, weekends, per diem)
  • WIC local agency staff (Peer Counselor, WIC Director, Breastfeeding Coordinator)
  • Quality Improvement
  • Breastfeeding mother that delivered in your facility (non-staff member)

The Texas Ten Step Scorecard Evaluation Tool can be used to help assess a facility’s readiness. The tool is used to score the application and supporting documents with designation awarded to those facilities that score 85 or higher. Having the task force take an honest approach to address the current facility policy with the evaluation tool is key to celebrating successes already present in the facility while identifying obstacles to address and overcome. For more information on scoring, visit the Scoring section at the bottom of this page.

Second Step- Review Application Learning Module

 Preparing Your ApplicationThis brief module outlines how to complete your Texas Ten Step application and prepares your for the review call.

Submit the following Ten Step support documents with your application, as applicable:

Step 1-Infant-Feeding Policy

Include current policies that address infant feeding (breastfeeding, supplementation, pumping and storage and use of assistive feeding devices for healthy, term infants). Do not include NICU policies, with exception of Step 4, skin-to-skin or kangaroo care (see below).

* Policies must have current revision and implementation date and necessary management signatures. If your policies are stored electronically and do not include signatures, please send a cover sheet with the manager or director’s signature verifying these are the current policies in use.

Step 2: Staff Education

Policy should address staff training. All training should include didactic and skills-based training- there is not a limit to how many hours or CEU’s are offered, however the recommended standard for staff education according to the Baby Friendly Hospital Initiative includes 15 hours of didactic and 5 hours of clinical skills training.

HHSC/ WIC Education- If your facility uses state-based education training for staff, when completing the application, please include the date/location of the training staff attended, and the percent of your total staff that received this training. It is not necessary to send content outlines for this training. If the class listed was completed on the WIC Partner Training site, please list location as “online”.

Non-DSHS Staff Education- Send content outlines for any training that staff are using as their documented breastfeeding training. Examples of what to send include PowerPoint presentations, educational articles, and bulletin or poster board education.

  • Provide outline of training(s) and % of maternity nursing staff educated on content; do not include class rosters.
  • All in-services, staff training, and conferences should be attended in the two years previous to application date.
  • Only list training that was provided to > 50% of maternity staff.
  • Training/ staff education documentation applies to maternity service nursing staff; non-nursing IBCLC continuing education is managed by the International Board of Lactation Consultant Examiners. Do not include or document training which is IBCLC-specific and has limited attendance unless the content obtained was then provided to general maternity service nursing staff for the purpose of  fulfilling Step 2 breastfeeding education. (ex: ILCA conferences with one attendee)

Step 3- Prenatal Breastfeeding Education

Policy should address prenatal education. Include course outline for any prenatal breastfeeding class or birthing class if it includes breastfeeding information. Content should reflect information listed in Step 3 of the Scorecard Evaluation Tool. Send scanned copies of any prenatal breastfeeding patient education materials given during community education.

Step 4- Skin-to-skin (all infants, regardless of feeding method)

Policy should address how skin-to- skin is managed for vaginal and cesarean deliveries. Include any policies that address kangaroo care in the NICU. This can include patient education materials on the Golden/ Sacred hour and continuous, uninterrupted SSC delayed procedures like weights/infant medications/bathing. On page 2 of the application, describe how transition is managed in the facility, list your current rooming-in rate and address whether the facility has a transition or well infant nursery.

Step 5- Show how to breastfeed and maintain lactation

Policy should address how breastfeeding assessments are conducted, how pump/ manual expression is taught and how formula preparation is managed. Information can include LATCH  or other assessment tools, patient education materials on pump set-up and hand expression, formula preparation/ storage/ paced feeding/ normal newborn stomach volumes.

Step 6- Supplementation

Policy should address how supplementation is managed for medical need. Information can include consents used and patient education materials as well as information on whether your facility has discontinued the use of formula gift bags. If all bags (including those used with breastfeeding mothers) have been removed, please list your facility on and include a screen shot of your facility’s listing.

Step 7- Rooming-In (all infants, regardless of feeding method)

Policy should address rooming-in. Describe how transition of the newborn is managed after vaginal and cesarean delivery (in-room, in transition nursery, in PACU, and include nursing care model used), how hospital visitation or any patient rest periods are managed.  Include any consents used, patient education materials on rooming-in, or pictures of signage used in hospital.

Step 8- Feeding on Cue (all infants, regardless of feeding method)

Policy should address feeding on cue, without limitation. Include information on how education is provided to patients, including formula fed infants. Include patient education materials on this subject and send a copy of the feeding log used by patients to track infant feedings during their hospital stay.

Step 9- Artificial nipples/ pacifiers/ alternative feeding devices

Policy should address artificial nipples, pacifiers and alternative feeding devices. Information to send can include patient education materials, consents and policies that address alternative feeding devices, artificial nipples and pacifiers. Include information provided to parents on alternative ways infant can be soothed and AAP recommendations on pacifier use.

Step 10- Discharge Support

Policy should address breastfeeding support following discharge. Include list of community breastfeeding resources- list should be dated to ensure list is current and should include content found under Step 10 of the Scorecard Evaluation tool or other applicable resources. If post follow up discharge phone calls are offered, include how calls are handled and documented. Describe how follow up with pediatric or other post-discharge provider is managed and include time frame for appointments (AAP recommendation).

Other information to include in application:

  • designation listing. Screen shot of listing preferred.
  • WIC Publications - if currently using WIC education materials obtained from the online catalog, please send a copy only of the front of the publication. This is to verify that you are using the most current version of the publication. Do not send the actual document, as this occupies additional filing space. Photocopy the front of the document and include the publication stock number and revision date on the copy.

*If you have electronic versions of your policy/ documents and application, please send via email to: When sending large email files/ attachments, please send in separate emails with the subject line referencing which step the content relates to. For example: Subject: Support Documents, Step 1 (or Step 2, etc.)

Mail all other documents to the address below. Do not include documents in hard binders as there is limited storage capacity.

Texas Ten Step Coordinator-Infant Feeding Branch

4616 West Howard Lane

Bldg. 8, Suite 840, MC 1933

Austin, TX 78728

 Scoring of application:

Each line item on the scorecard evaluation tool is worth 2 points for a total of 100 points. Points are assigned as follows:

  • Full credit (2 points) if line item is included in the policy.
  • Partial credit (1 point) if line item is not included in policy but documentation supports it is a part of practice.
  • No credit (0 points) if line item is not included in policy and not supported by documentation.

Facility contacts are provided the opportunity to review the scorecard before final determination on score is made. This is conducted through a technical assistance conference call or email (if applicable).

Texas Ten Step designation is awarded with a score of 85 or higher along with current designation through the Texas Mother Friendly Worksite program.