Annual Report 2020

Greetings from our Leaders

Lisa Piercey, MD, MBA, FAAP

Commissioner for the TN Department of Health

Morgan McDonald, MD, FACP, FAAP

Deputy Commissioner for Population Health for the TN Department of Health

Victor Wu, MD, MPH

Chief Medical Officer for the TN Division of TennCare

Susan Guttentag, MD

TIPQC PI & Oversight Committee Chair

Anna Morad, MD

TIPQC Infant Medical Director

Jessica Young, MD, MPH

TIPQC Maternal Medical Director

Rolanda Lister, MD

TIPQC Officer for Health Equity

Patti Scott, DNP, APN, NNP-BC, C-NPT

TIPQC Infant Quality Improvement Specialist

Bonnie Miller, RN, MSN

TIPQC Maternal Quality Improvement Specialist

Mike DeVoe, MD

Opioid Exposed Newborn Project State Leader

Courtney Gutman, MD

Safe to Sleep Project State Leader

Oversight Committee

The Oversight Committee is critical to the work of TIPQC.  Special thanks and much gratitude for your contribution to improved care for mothers and infants in Tennessee.  

  • Jona Bandyopadhyay, MD, MPH
  • Kelly Bennett, MD
  • Joel Bradley, MD, FAAP
  • John Buchheit, MD
  • Mary Catherine Burke, DMCP
  • Tara Burnett, MD
  • Greg Canella, MD
  • Chris Clarke, RN
  • Melissa Davis, DNP, CNM, FNP
  • Mike DeVoe, MD 
  • Cornelia Graves, MD
  • Susan Guttentag, MD, Chair
  • Brian Hackett, MD
  • Shawn Hollinger, MD
  • Jeanne James, MD
  • Joseph Kipikasa, MD
  • Morgan McDonald, MD, FACP, FAAP
  • Diana Moses, RN, BSN, MBA
  • Ajay Talati, MD
  • Danielle Tate, MD
  • Kevin Visconti, MD
  • Lynlee Wolfe, MD
  • Victor Wu, MD

Ex Officio
  • Nikki Zite, MD, MPH
  • Anna Morad, MD
  • Jessica Young, MD, MPH
  • Reddy Dhanireddy, MD
  • Brenda Barker, MEd, MBA
Subcommittee Members
  • Kitty Cashion, RN-BC, MSN
  • Marlee Crankshaw, DNP, RN, CNML
  • Melanie Ford, RNC
  • Deena Kail, BSN, RN, MBA
Maintenance of Certification (MOC) Committee
  • Tara Burnette, MD
  • Donna Whitney, MD

TIPQC Operations Staff

Staff bios and details are available on our website.

Susan Guttentag, MD
Brenda Barker, MEd, MBA
Anna Morad, MD

Jessica Young, MD, MPH

Rolanda Lister, MD
Patti Scott, DNP
Bonnie Miller, RN, MSN
Steven Compton, JD
Amanda Nally, BS

Theresa Scott, MS
Mike DeVoe, MD

Courtney Gutman, MD
Cornelia Graves, MD
Danielle Tate, MD

2020 in Pictures

Thank you to every stakeholder who made a difference for moms and babies this year.
You are the real heroes in Tennessee!

2020 March of Dimes Report Card

Tennessee Scores a D- on the March of Dimes report card for 2020 with an 11.2% preterm birth rate. While our disparity ratio did improve, the preterm birth rate among Black women in our state is 44% higher than the rate among all other women.

Some positives from the report for Tennessee include Medicaid extensions, our state having below average preterm birth costs, the work of our Maternal Mortality Review, and our perinatal quality collaborative.

  • January

    Golden Hour Impact Statement

    TIPQC’s Golden Hour project is published! 

    Site Visits

    Site visits & C-suite conversations continued with the OUD/OEN Leadership team visiting TriStar Hendersonville, Regional One Health, Methodist Germantown, and Baptist Memorial.

  • February

    iNIQC Transitions of Care

    Five teams joined this Vermont Oxford Network (VON) collaborative to improve processes and practices of critical newborn transitions to affect outcomes and experiences for infants and their families.

    VON NAS Center of Excellence

    Thirty-nine (39) teams have continued working on all 19 mini-modules. TIPQC has 2,199 learners enrolled having completed 18,088 courses through the end of December 2020. Four hundred fifty-four (454) learners have completed all modules. Eight (8) teams have received VON designation of Center of Excellence Award.

    TriStar Hendersonville is the first hospital in Tennessee to achieve Vermont Oxford Network “Center of Excellence for NAS Training.”

    TEIS & TNAAP Workgroup

    In February, TIPQC participated in several meetings as a part of a workgroup with the Tennessee Early Intervention System (TEIS) & Tennessee American Academy of Pediatrics (TNAAP) leadership advocating for services for opioid exposed newborns (OEN), in addition to those infants diagnosed with Neonatal Abstinence Syndrome (NAS).  As of March 2020, TEIS began accepting the ICD-10 codes for OEN, allowing these infants to receive services.

  • March

    2020 Annual Meeting

    TIPQC brought together more than 420 physicians, nurses, hospital administrators, insurance companies, families, state officials, community groups, and many other stakeholders on March 2-3, 2020 at the Cool Springs Marriott in Franklin. Over the two days, participants were able to learn about maternal and child health issues, quality improvement projects, and hear from noted state and national speakers.

    NARCAN Training

    Understanding and utilizing NARCAN is critical in the fight against opioids.  Every provider, clinician, nurse, and family member needs to have this life saving training and resource. TIPQC was able to offer NARCAN training to over 50 attendees during the Annual TIPQC Meeting and again in November at the OUD/OEN Learning Session with 28 attendees.

    NARCAN resources are available on our website, both in English and Spanish.

    Safe to Sleep Project Launch

    The Safe to Sleep Project launched at the 2020 Annual Meeting. Fifteen teams participated in monthly huddles as well as Learning Sessions in July and November. Thirteen (13) teams have captured data on over 1,500 Safe Sleep audits (June to December 2020) performed in the hospitals’ Newborn Nurseries, Neonatal Intensive Care Units (NICUs) and Parent Rooms. As a state, the percent of audits compliant with the American Academy of Pediatrics (AAP) guidelines continues to show improvement month to month.

    COVID Resources

    Due to the pandemic, TIPQC huddles have addressed challenges & barriers during COVID-19 for our at-risk population, as well as a resource page on our website. 

  • April

    Continuing Education and Maintenance of Certification

    Fifteen (15) Continuing Medical Education (CME) training videos were published to the TIPQC website in 2020, featuring the OUD and OEN projects as well as talks on Safe to Sleep and Quality Improvement.

    TIPQC has been able to offer free CME to over 188 people viewing these videos. Over 598 viewers utilized the TIPQC YouTube and hospital in-house trainings.

    This past year 264 Providers earned 711 CME Credits thanks to the generosity of Vanderbilt University Medical Center, School of Medicine, Continuing Medical Education Office. Thanks to TriStar Summit Medical Center, 389 Nurses were able to obtain 1,827 contact hours through Continuing Nursing Education (CNE) after attending TIPQC trainings.

    Since the current projects were approved, 51 Physicians have received a total of 1,290 Maintenance of Certification (MOC) credits through the American Board of Pediatrics (ABP) and the American College of Obstetricians and Gynecologists (ACOG) Multi-Specialty Portfolio Program (MSPP).

  • May

    Speakers Bureau Training

    TIPQC began training with Matt Moran, professional speaking coach, with a series of online modules as well as bi-weekly, hour-long training sessions with 47 potential speakers as well as staff and Board members. TIPQC has developed the tool kit, agreement for speakers, and completed 6 talks to be shared at no cost to participating facilities.

    Topics Include:

    • Opioid Use Disorder in Pregnancy
    • Maternal Hypertension
    • Postpartum Hemorrhage
    • Health Equity
    • Opioid Exposed Newborn
    • Safe to Sleep

  • June


    TIPQC was pleased to offer top-notch masks to OUD teams to distribute to their pregnant clients & mothers through a partnership with Judson Church. Over 1,000 masks were distributed.

    OUD/OEN Learning Session

    The Opioid Use Disorder and Opioid Exposed Newborn Learning Session was held virtually on June 22 with over 110 attendees. Meeting highlights included a mother’s perspective, as well as Amy Koslick with the Department of Child Services (DCS) discussing Plans of Safe Care. Teams also reflected on the “new normal”– the impact COVID-19 and racism have on this population. In addition, teams were able to share resources created during the project.

  • July

    Safe to Sleep Learning Session

    The first Safe to Sleep Learning Session took place virtually on July 7, 2020. The over 110 attendees heard from family member, Marlena Shelton, RNC, Tennessee Department of Health’s Rachel Heitmann, MS, and Medical Examiner Darinka Mileusnic-Polchan, MD, PhD.  In addition, teams discussed first PDSA cycles, resources including the Safe to Sleep Speaker’s Bureau, and NANN Materials.

    NANN Safe Sleep Guides Purchased

    The National Association of Neonatal Nurses recently released their set of evidence based guidelines on Safe Sleep. TIPQC purchased these guidelines for each of the project teams in order to provide the teams with the resources they needed for policy development and staff/parent education.

    American Society of Addiction Medicine Buprenorphine Waiver Training

    American Society of Addiction Medicine (ASAM) Buprenorphine Waiver training was held on July 31. TIPQC utilized a grant from American College of Obstetricians and Gynecologists’ (ACOG) Alliance for Innovation on Maternal Health (AIM) covering most of the cost with providers covering a small $25 fee. 

    TIPQC has filmed an interview with a patient on Medically Assisted Treatment (MAT).  We featured this at our November Learning Session and hope both providers and patients will utilize this resource.

    In addition, TIPQC has recorded a podcast on MAT.

  • August

    Speakers Bureau Launch

    Six educational talks have been circulating around the state, with local physician and nursing leaders delivering them. TIPQC speakers have given 16 talks, primarily to hospitals, with a total of 369 attendees. We look forward to expanding this in 2021.

    Opioid Use Disorder Pregnancy Checklist

    TIPQC developed, printed & disseminated 1,500 Pregnancy Checklist Trifolds to teams.

  • September

    Health Equity Series – Session 1

    The first of a three-part learning series on Health Equity was held on Tuesday, September 29 where Rolanda Lister, MD presented “Racial Disparities in Maternal Health Outcomes.” Approximately 75 were in attendance. TIPQC was pleased to welcome Dr. Lister as the Officer for Health Equity in July 2020.

  • October

    Podcast Launch

    Our podcast, Healthy Mom Healthy Baby TennesseeTM, launched on October 12, 2020 and had 300 downloads with 8 episodes published in 2020 – click below for topics and to sign up for weekly episodes released each Monday in 2021. Thanks to a grant from Alliance for Innovation on Maternal Health (AIM), TIPQC was able to purchase podcast equipment.

    Blood Pressure Cuffs Purchased

    TIPQC joined the National Preeclampsia Foundation’s Remote Monitoring Research Project. TIPQC purchased 828 blood pressure cuffs for the seven (7) Severe Maternal Hypertension Project pilot hospitals to give to at-risk pregnant & postpartum patients.

    In December, TIPQC shared a podcast episode featuring the Preeclampsia Foundation spokesperson, KK Dixon. KK shared her experience with eclampsia.

    Health Equity Series – Session Two

    Friday, October 30, we hosted the second of a three part series on Health Equity with Dr. Connie Graves “Equity through the Patient’s Eyes” with approximately 53 in attendance.

    Safe to Sleep Learning Session

    The TIPQC Safe to Sleep Learning Session on October 20 featured cultural perspectives on infant sleep as well as suggestions for understanding and communicating with parents, thus improving infant sleep. Speakers included Adriana Bialostozky, MD discussing the Latinx population, Wakako Eklund, DNP, NNP-BC with Japanese and Asian cultures, Angela Booker, RN sharing around the Black culture as well as Barbara Engelhardt, MD highlighting her Eastern European and “grandmotherly” perspective when her family lost a baby to infant sleep. In addition, Anna Morad, MD discussed unsafe sleep comfort products and Courtney Gutman, MD discussed resources and current unsafe sleep practices. All 15 teams participated, with over 79 attendees, and were treated to a primer on run charts by Theresa Scott, MS. Teams left with multiple resources, new ideas, and ready to begin the next PDSA cycle on teaching “safe to sleep” practices in the hospital setting.

  • November

    Severe Maternal Hypertension Project Kickoff

    Seven (7) teams have begun the pilot phase of this project, after working several months developing this project, as well as the tool kit, in combination with the AIM Severe Maternal Hypertension Bundle. The Infomercial is planned for February to enroll statewide teams. The Association of Women’s Health, Obstetric and Neonatal Nurses’s (AWHONN’s) POST-BIRTH Warning Signs will also be purchased for any hospital team who is interested in this nursing and patient education. Pilot teams have been distributing the blood pressure cuffs through the Preeclampsia Foundation for patients needing home monitoring.

    OUD/OEN Celebration

    The OUD/OEN Learning Session and Celebration was held on November 10, 2020 with over 80 attendees. Teams received recognition pins for their work on this project. We also want to give our continued thanks to United Healthcare and Joel Bradley, MD, FAAP for their financial sponsorship of this project. Wave 2 was announced and will begin January 2021.

    Coaching Calls

    TIPQC project coaching calls included a maternal lead physician and nursing call on 1/8/20 as well as multiple individual hospital coaching calls monthly focusing on data collection, huddle information, and project implementation. A total of over 40 OUD team hospital QI coaching calls were made and over 60 OEN coaching calls have been made.

  • December

    OUD/OEN Project Closes Wave 1

    Notable data improvements include:

    • 60% increase in pregnant women with OUD receiving Medication Assisted Treatment (MAT)
    • 75-87% of the Opioid Exposed Newborns (OEN) were able to room-in with their biological mother
    • 70% of the OEN were discharged home to their biological mother

TIPQC Across the State & Nation

TIPQC is frequently asked to share the work our teams are doing across Tennessee and the United States.

  • Kentucky Perinatal Quality Collaborative Speaker, March 2020
  • Louisiana OUD, Expert Faculty, Spring 2020
  • Tennessee Department of Health (TDH) Maternal Mortality Review Speaker, April 2020
  • Colorado Perinatal Quality Collaborative & Department of Children’s Services, April 2020
  • TDH Safe Sleep Speaker, May 28, 2020
  • Tennessee Department of Health (TDH) Perinatal Advisory Committee (PAC) Speaker, April 2020
  • CMS Lessons from the Front Lines: COVID-19, June 2020
  • Institute for Healthcare Improvement (IHI) Collaborative College, May & June 2020
  • National Network for Perinatal Quality Collaboratives (NNPQC) & Alliance for Innovation on Maternal Health (AIM) Meeting Speaker, June 2020
  • TIPQC Annual Retreat strategic planning & Unconscious Bias Training with Dr. Arie Nettles, July 2020
  • AIM State Leaders Meeting Speaker, October 2020
  • THD PAC Speaker, October 2020
  • Illinois Perinatal Quality Collaborative Speaker, October 2020
  • National Network of Perinatal Quality Collaboratives (NNPQC) Speaker, November 2020
  • Ohio Perinatal Quality Collaborative, November 2020
  • Tennessee Association for State and Territorial Health Officers (ASTHO)
  • Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Workgroup, November 2020

Our Partner Organizations