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Background: Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide quality improvement collaborative that elected to design and develop a project to address Tennessee's low breastfeeding rates. Purpose: To improve the health of Tennessee infants and mothers by increasing initiation and duration of breastfeeding through systematic implementation of processes with high reliability (> 90%) that promote and support breastfeeding in the delivery setting. Methods: A toolkit was created using the evidence-based practices of the Ten Steps to Successful Breastfeeding and the USBC Toolkit, “Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding.” Eleven hospitals across the state of Tennessee are currently participating in the project since the state-wide kick-off in July 2012. Participating hospitals established improvement teams of stakeholders, and began collecting exclusive breastfeeding rates at hospital discharge, according to the Joint Commission Perinatal Core Measure 5 guidelines. After baseline data collection, the centers are implementing one or more of the 10 Steps to Successful Breastfeeding by using rapid Plan-Do-Study-Act (PDSA) cycles. Reliability of implementation is monitored by process measure audits. Web-based data-entry through REDCap provides on-demand run-charts to each individual center. Monthly webinars facilitate sharing of best practices between geographically distant centers, as well as sharing of the state-wide data in aggregate. Each participating center creates a Leadership Report highlighting its recent data on exclusive breastfeeding as well as selected PDSA cycles. Centers also share lessons learned and query participating centers on specific challenges. Additionally centers are invited to attend a face-to-face annual state-wide meeting with nationally recognized experts, as well as two regional workshops per year to share challenges and successes, and to learn quality improvement strategies from the TIPQC Quality Improvement team. Results: Baseline exclusive breastfeeding at discharge according to the Joint Commission criteria was 35% in aggregate. Initial data demonstrate that centers have noted some success in implementing changes in all of the Ten Steps to Successful Breastfeeding. Skin-to-skin care has been markedly increased in several centers, with some centers specifically targeting skin-to-skin care after C-Sections. Centers have also seen increases in rooming-in, staff training, and adoption of a breastfeeding policy. Upstream opportunities have been identified for prenatal education with providers of prenatal care (Step 3). Downstream opportunities have been identified for community support at discharge from the center (Step 10). Baseline data in the first 5 months of the project from over 7000 maternal-infant dyads (approximately 25% of Tennessee births) highlight improvement opportunities on all of the Ten Steps. Conclusions: This project serves as a model for how quality improvement methodologies may be combined with use of distance-learning and web-based data entry and reporting to facilitate implementation of evidenced based practices to increase breastfeeding rates.

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