The Perinatal Committee identifies the following to be creditable for active participation at the committee level:

• Attendance is a prerequisite to meaningful participation and as such, the Perinatal Committee requires documented attendance of 75% of committee meetings and/or workgroups by the primary and/or identified alternate organization/agency representative.
  • Virtual attendees are highly encouraged to utilize video capabilities where available to facilitate meaningful discussion and participation in NCTTRAC meetings and events.
• Meet committee requirements for position-specific attendance; the following identified organization representatives listed below will collaborate to meet 75% of perinatal meeting attendance rate:
  • Maternal/Neonatal Program Managers
  • Maternal/Neonatal Medical Directors
  • Delegated/Alternate Voting Representatives, as documented.
• Each member will have 100% participation in all NCTTRAC surveys, based on their facility’s designation program.
• Each member will have 100% participation in at least one NCTTRAC SMART Goal, based on their facility’s designation program.
  • For members with a capable registry, evidence of data submission to outsourced data reporting service on a quarterly basis to be provided to NCTTRAC.

Chiefs and Executives Dashboard

Members can utilize the NCTTRAC Chiefs and Executives Dashboard to review the overall performance of their respective member organization; including information on the following:

• Organization’s Membership
• Active Participation Status
• Attendance in committee meetings
• Participation in data submission requests
• Status of different agreements and contracts

Additionally, member organizations can view their individual participation/performance status and compare their own performance against other member organizations throughout TSA-E.

Chiefs and Executives Dashboard

The following are the current subcommittees, workgroups, and/or taskforces in effect for any committee related projects or initiatives:

SMART Goal Workgroup

The workgroup meeting the Third Friday of every month from 11:00 AM – 12:30 PM. Meetings rotate between Neonatal and Maternal specialties each month.

• Neonatal Co-Lead:
  • Alaana Garris, MSN, RNC-NIC, NNP-BC                                                                               
  • Neonatal Levels Program Manager, Methodist Charlton Medical Center

• Maternal Co-Lead:
  • McKenzie Steelman, RNC-OB                                                                                
  • L&D Supervisor/Maternal Designation Coordinator, Texas Health Frisco

• Assist committee with evaluating regional data, identifying data needs and/or requirements. 
• Review, evaluate, and recommend to the Perinatal Committee referrals and tools. 
• Share education, information, and best practices related to the following:
  • Texas Alliance Innovation Maternal Health (TexasAIM)
  • Texas Collaborative for Healthy Mothers and Babies (TCHMB)
  • Perinatal Care Region/Regional Advisory Council Alliance (PCR/RAC Alliance)
  • Perinatal Advisory Council (PAC).  

• Current projects include:
  • Maternal Severe Hypertension (MSH) Project
  • Safe Sleep Project
  • Maternal Mental Health Project

• Past projects:
  •  
  • Newborn Admission Temperature (NAT) Project

Safe Sleep Taskforce

The taskforce meetings are the Fourth Monday of every month from 10:00 AM – 11:00 AM.

• Taskforce Co-Lead:
  • Bernadette White, MD                                                                                
  • Cook Children’s Medical Center

• Taskforce Co-Lead:
  • Suzanne Whitbourne, MD                                                                                
  • Texas Health HEB

Maternal Mental Health Taskforce

The taskforce meetings are the Second Monday of every month from 10:00 AM – 11:00 AM.

• Taskforce Co-Lead:
  • Arpitha Chiruvolu, MD, FAAP                                                                                
  • Baylor Scott & White – McKinney

• Taskforce Co-Lead:
  • Suzanne Whitbourne, MD                                                                                
  • Texas Health HEB

The following are the current data initiatives in effect for the committee:

Maternal Severe Hypertension (MSH) Project

The Perinatal Committee developed this maternal goal to identify current practices in treatment times for Severe Hypertension in Maternal patients, as well as a brief inquiry in follow-up care. Through this limited data gathering initiative, the NCTTRAC Perinatal Committee will be able to:

–  Conduct gap analyses

–   Identify areas for improvement

–   Improve care and outcomes for maternal patients.

Gap analysis findings will be presented to the committee and any other stakeholder with an interest in improving patient outcomes.

Maternal Severe Hypertension (MSH) Survey Link MSH Survey Participation Dashboard  

Perinatal Safe Sleep Project

In 2021, SIDS was the 3rd leading cause of death in infants behind congenital anomalies and  newborns affected by maternal complications in the State of Texas (DSHS 2021 State Dashboard Data). The Perinatal Committee has chosen the Safe Sleep project in response by identifying where our region is needing support. Through this data gathering initiative, the committee has established the following goals:

• Create best practices on safe sleep (developing a hospital process)
• Increase education to families on safe sleep NBN/Post-partum, NICU
• Increase safe sleep modelling in NBN and NICU

The NCTTRAC Safe Sleep Baseline Report dashboard was developed using results from the baseline survey, which provided an initial analysis of current regional processes within PCR-E designated facilities. Data was collected from 50 perinatal-designated facilities between April and May 2025, with plans to follow up on progress after implementing regional best practices, educational resources, and newly developed guidelines.

YOU MUST BE LOGGED IN TO VIEW THE DASHBOARD. USE THE RED “LOG-IN” BUTTON AT THE TOP RIGHT CORNER OF YOUR SCREEN TO LOG-IN TO WWW.NCTTRAC.ORG.

Maternal Mental Health Project

The Perinatal Committee identifies the Maternal Mental Health project as one of the current Maternal-specific data initiatives. This project will focus on enhancing maternal mental health support in postpartum care, with the inclusion of a NICU element where data is available. Through this data gathering initiative, the committee has established the following goals:

• Help adopt an algorithm for mothers who score “moderate to high” on EPDS.
• Increase education/resources to mothers in post-partum who leave the hospital and again if baby is in NICU at 2 weeks of admission.
• Increase Peri-Pan utilization (e.g., TXMMR/DSHS joint bi-annual report 2024, as a recommendation to decrease maternal mortality)

The NCTTRAC PPD Screening Baseline Report dashboard was developed using results from the baseline survey, which provided an initial analysis of current regional processes within PCR-E designated facilities. Data was collected from 50 perinatal-designated facilities between April and May 2025, with plans to follow up on progress after implementing regional best practices, educational resources, and newly developed guidelines.

YOU MUST BE LOGGED IN TO VIEW THE DASHBOARD. USE THE RED “LOG-IN” BUTTON AT THE TOP RIGHT CORNER OF YOUR SCREEN TO LOG-IN TO WWW.NCTTRAC.ORG.

Archived Initiatives

Newborn Admission Temperature (NAT) Project

The Perinatal Committee created the Newborn Admission Temperature (NAT) initiative to increase the proportion of newborn infants with admission temperatures within normal limits through the implementation of best practices.

This project has been archived, but the historical report can be viewed below:

 NAT Survey Participation Dashboard

State Initiatives

The NCTTRAC Perinatal Committee also works in collaborating with Texas Collaborative for Healthy Mothers and Babies (TCHMB) in any statewide initiatives and state data integration with PCR-E facilities’ data.

TCHMB Initiative Overview Webpage 

This Document Library allows members to review the respective committee documents and resources, as approved by the member organizations. You are currently viewing the PUBLIC view. You must be logged in to view the dashboard. Use the red “Log-In” button at the top right corner of your screen.

The Texas Department of State Health Services (DSHS) designations in Maternal, Neonatal, Stroke, and Trauma require that the hospital applicant show they are “active participants” in the local RAC’s system of care in which they seek designation. The NCTTRAC General Membership has set this standard to include requirements that these hospitals must be approved members of the RAC, must participate in any performance improvement initiative requested, and submit data as requested for various Committee and Regional assessments.

To request a RAC Letter of Participation for your upcoming Designation Survey, please utilize the Support Ticket System:

NCTTRAC Support Ticket System  –  RAC Participation Letter Request

For further information regarding Designation Support, please visit the Designation Support Webpage:

Designation Support Webpage

For further information regarding DSHS Designations, please visit the each DSHS Designations’ Webpage:

DSHS Maternal Designation Webpage

DSHS Neonatal Designation Webpage