Case

Study

Use of the Baldrige

Framework by
the Tennessee
Department
of Health
Micky Roberts, Caroline Chinouth Hurt, Emily Rushing, Laura Conner, Michael Railling,
and Bruce Behringer

T he societal responsibility of the Tennessee Department of Health

(TDH) is to protect, promote, and improve the health of people who
live, work, and play in the state. In 2011, Tennessee recorded poor state
health rankings as influenced by causes of morbidity and mortality.1
The Tennessee Department of Health (TDH) leadership highlighted this
problem by choosing tobacco as one of the big four public health issues
(tobacco use, obesity, physical inactivity, and substance abuse) that lead
to excess mortality and healthcare costs in the state.2 To address those
expectations, new leaders developed a multi-year plan to adopt, diffuse,
and integrate the Malcolm Baldrige Performance Excellence framework
(Baldrige) and its quality principles in 2012 across work systems and pro-
cesses (see Figure 1). This gave the department the impetus to embrace
broad systems changes by transforming its efforts to focus action toward
greater preventive, community services.3

4 The Journal for Quality & Participation April 2019

www.asq.org/pub/jqp 5
 State health depart- Figure 1: Baldrige Framework Categories
ments provide legislatively
mandated regulatory and
clinical services. TDH’s
budget consists of revenues Environment, Relationships, and Strategic Situation
from state appropriations,
local government contri-
butions, service fees, and
federal grants. TDH oper-
ates 89 local (county) health
1 7
departments (LHDs) and Leadership
contracts with six metro-
politan counties to deliver
services. Overall, public
health entities and the
5,584-member statewide
public health workforce
Measurement, Analysis, and Knowledge Management
are charged with disease
prevention and popula-
tion health improvement.
Services and programs are managed through LHDs
and clinically have traditional compliance-based
process protocols with standardized performance
reporting and annual budgets. Adoption of a new
quality focus engendered by the Baldrige frame-
work allowed expansion of quality precepts to both
clinical and community-based services. To imple-
ment this approach, greater flexibility was required
to encourage employee engagement and decision
making, leading to greater discretionary efforts
focused on improvement.
One of the leading causes for morbidity and
mortality in Tennessee was smoking. In 2013,
the General Assembly appropriated $15 million
from Tennessee’s U.S. Master Tobacco Settlement
Agreement (MSA) revenues for a three-year effort
to address the seemingly intractable smoking
problem. TDH launched the Tennessee Tobacco
Settlement Program (TTSP) and used the seven
Baldrige framework categories to implement new
program planning, operations, and evaluation
methods (see the first online supplemental article).
Responsibility for a strategic planning process
for TTSP was given to LHDs. Counties engaged in
a local participatory process to assess work systems
and their supporting processes to address three tar-
geted population health goals: reducing pregnancy
smoking and secondhand smoke exposure for
young children as well as helping youth to choose
not to smoke. TTSP publicly announced statewide
success in 2017, reducing pregnancy smoking by
6 The Journal for Quality & Participation April 2019
Organizational Profile:
2 5
Strategic Planning Workforce Focus
Results
3 6
Customer Focus Operation Focus
4
16  percent, use of emergency departments for
children for a diagnosis of asthma (smoking is a
trigger for asthma attacks) by 18 percent, and the
percent of eighth graders who chose to smoke by
46  percent. Attention to the human side of pro-
moting quality was the key to such statewide
improvements. Actions taken collectively by LHDs’
staff relied on individual beliefs that integrating
quality and performance-management principles
into work processes would finally “move popula-
tion health needles” that seemed to perpetually
point to poor national rankings for Tennessee.
TDH Approach to Integrating Quality Principles
Into One Statewide Public Health Program
TDH use of MSA funding for prevention pro-
gramming provided the department with a unique
opportunity to design this new multi-year tobacco
use prevention and control program that supported
employee initiative and innovation (see Table
1, in first online supplement). Quality improve-
ments, grounded in seeking program effectiveness
and efficiency over operational compliance, were
emphasized through increased local ownership of
work processes and reinforced in programmatic and
individual performance plan (IPP) accountabilities.
TDH distributed MSA funding directly to coun-
ties. LHDs were charged to assess county needs,
develop their own annual investment plans and
budgets, and set three-year quantitative outcomes
as goals for the three specific targets (see Table 1,
in first online supplement). This process ownership
approach reflected a more human side of staff par-
ticipation as opposed to draconian one-size-fits-all
programmatic mandates. Reasonable risk taking
and innovation goals were included in key job class
and individual performance plans that oversaw
county-wide efforts.
State allocations are traditionally awarded
through annual budgets. TTSP provided three-year
budgets to counties, which allowed LHDs adequate
time to count numbers of services and participants
(outputs) and begin to document longer-term pro-
gram results (outcomes). This included a shift away
from focusing on annual monetary/grants spend
down as an indicator of financial viability, to one
focused upon a return on investment (ROI). As an
example, one leading aggregate measure of finan-
cial return came from documented reductions in
pregnancy smoking that led to reducing the number
of low birthweight births and prevented expensive
neonatal intensive care hospital costs.
Instrumental to TTSP success was reapplying
learning that took place on two levels. First, TDH
undertook staff development workshops and plan-
ning meetings through the Office of Performance
Management to systematically teach performance
excellence (PE) and performance improvement (PI)
tools. LHD staffs were challenged to reassess cus-
tomer satisfaction, dissatisfaction and engagement
to develop strategies that resulted in expanding local
support and resources to address smoking issues.
Second, from a program management standpoint,
TDH used the Baldrige approach, deployment,
learning, and integration (ADLI) tool4 to con-
tinuously gauge the maturity of work processes
(for details, see first online supplemental article).
This information is discussed in more detail in the
online supplement.
The alignment of TTSP within the department’s
adoption of Baldrige was reinforced again as TDH
partnered with Tennessee Center for Performance
Excellence (TNCPE), the state Baldrige affiliate,
to promote training and diffusion of PI tools and
techniques. This included use of lean principles
and the four aspects of plan, do, check and act
improvement cycles (PDCA) across the state public
health enterprise.5 Lean6 training was offered to
encourage improvement of business processes from
the customer point of view and to identify work
process steps that add value. Beginning in 2012
as the department completed its organizational
assessment and achieved a TNCPE Level 1 Interest
Award, leaders consistently sought opportunities to
exemplify how the seven Baldrige categories were
deployed to guide performance excellence efforts.
The department supported Baldrige Examiner train-
ing for 132 LHD employees in the course of six
years through TNCPE. The examiners then formed
an internal Baldrige Advisory Group (BAG) to
promote enterprise-wide efforts to diffuse quality
improvements into LHDs and other TDH services
and programs. This quality atmosphere supported
TTSP implementation and, in turn, examples of
TTSP processes and outcomes supported individu-
als’ involvement in the departmental improvement
drive. As a result, there was substantial growth in
county and program-level applications for TNCPE
awards as well as submissions to an internal depart-
mental Rapid Improvement Events (RIE) Challenge7
from 2015-17.
Quality Management, Techniques, and Tools
Baldrige’s six process categories and the one
results category became the framework for a state-
wide longitudinal approach for integrating planning,
operations, and evaluation of TDH work systems
and processes as demonstrated (see Table 1, in first
online supplement). The management approach for
TTSP included use of process maps, value streams,
and other assessment tools to help LHDs improve
work steps to create value and ownership as well as
expanded community collaboration and coalition
development (see Figure 2). Another traditional
public health tool, the logic model, became a build-
ing block to assist counties in choosing from an
array of evidence-based or locally developed inter-
vention projects to be included in county-generated
annual investment plans.
TTSP was aligned with a new departmental
participatory strategic planning process begun in
2012, which was based upon Baldrige principles.
TTSP was seen as an initiative aligned directly
with the TDH mission (Protect, promote, and
improve the health and prosperity of people in
Tennessee), vision (A recognized and trusted leader,
partnering and engaging to accelerate Tennessee to
one of the nation’s 10 heathiest states), and state
health plan (To reduce tobacco use and exposure
to secondhand smoke). New reporting formats,
using a web-based portal, were designed to capture
LHD achievements that contributed to statewide
population health improvements articulated in the
mission and vision.
www.asq.org/pub/jqp 7
 Human Resources Management—Employee
Involvement, Facilitation, and Coaching
Influenced by the Baldrige framework, the State
of Tennessee’s Department of Human Resources
initiated use of SMART (specific, measurable,
actionable, relevant and time-bound) objectives
for the state’s workforce. Coaching was deployed
to departments and through supervisors to all staff.
The TDH strategic plan, annually refreshed with
employee participation, became instrumental in
supervisor and employee discussions to develop
individual performance plans and SMART objec-
tives. Workforce engagement was evidenced by
the almost 3,000 employee responses to surveys
inviting comments and improvements to the plans.
Later, TDH further aligned with Baldrige principles
by establishing real pay for performance measures,
including shifting the performance calculation to
include a 30 percent customer-service weighted
aspect. TTSP supported and benefitted from this
movement, encouraging greater county attention
to customers and non-traditional partners such as
schools, substance-abuse coalitions, local business,
athletic associations and youth teams to advocate for
local smoke-free policies. Individual work outcome
statements included risk and innovation; therefore,
employees participated in implementing, document-
ing, and nominating successful use of PI tools such
as value-stream mapping and the 5 Whys.8
Leadership Theories and Practices
Senior leaders invited LHD staff to become part-
ners in planning, not just implementing programs,
resulting in several new policies and approaches.
First, Baldrige helped county health departments
adopt a new view of how the department’s mission

Figure 2: Tennessee Tobacco Settlement Program Strategic Map, 2014-2016

Change community Actively prevent Reduce lifetime

smoking norms youth smoking excess medical costs

Approach: dual strategies: enhance

school-based tobacco use prevention
curricula, and students as messengers through Prevent and reduce youth tobacco use
peer-to-peer leadership training and events
Deploy: each county chose different set of
activities from evidence-based models;
counties develop statewide FACT conference to Community Cessation
School based Events Peer to Peer
create sense of statewide scope for students Support Services
Learning: multiple events, the same message Offer to partner
required to reach students; youth willing to Michigan Signage: benches, Community Teens Against
to create culturally
Model billboards, t-shirts runs Tobacco Use
help others not to start or stop smoking acceptable service
(including family); social media is an effective
tool; gain active and early youth commitment Events:
State youth Tennessee Teens
Kick Butts, Youth councils QuitLine
like signing pledges FACT Summit Talk Tobacco
Carnival, others
Integration: Coordinated School Health
partnership enables locally creative projects;
Community TTI youth
student-created graphics and message used Kindergarten
agency leadership Athletic teams
throughout county coloring books
coordination institutes

2014-2016 Outcomes Social media to Student Health

Poster New social
promote awareness Councils, HOSA
+ All counties with school tobacco use contests
and concern
media supports
and other clubs
prevention programs
+ 51 counties use Michigan Model
Coaches
curriculum for 125,000 students education
+ 271 youth teams including 1,962
youths and 309 adults trained in three
peer-to-peer models with 703 school Improve awareness, knowledge and attitudes about health impacts of tobacco use
based and 233 community-based,
student-led prevention projects
Activate individuals and youth groups to demonstrate support against tobacco use

Partner with schools and agencies to support action against youth tobacco use

8 The Journal for Quality & Participation April 2019

and vision could be achieved by reaching beyond
LHD clinic walls and expanding a proactive, com-
munity-based approach to public health. This
included leveraging the tobacco use awareness and
partnerships of county health councils associated
with county health departments (see first online
supplement). Second, leaders created an environ-
ment where the use of PI tools became a matter of
regular operations rather than the exception. Third,
continuous communication from leadership and
coaching with employees led to rewards for tak-
ing reasonable risk through new innovations and
accelerating use.9 Leaders created an environment
to support testing multiple innovations within
TTSP. An employee Rising Stars team10 composed of
emerging TDH staff leaders identified and presented
industry-best practices in tobacco use prevention
and control projects. This gave program and field
staff an interactive opportunity to participate in deci-
sion making and to demonstrate leadership skills.
TTSP program summative results were contained
in County Health Improvement Plans Against
Tobacco Use (CHIPATUs)11 through which LHD
staff were able to demonstrate new public health LHDs became publicly exposed to risks of success
skills and program accomplishments (see Figure and failure of changing behaviors among priority
2). LHDs also presented their annual work process populations over which they had no real control.
improvements from PDCAs and strategic maps, Counties were required to share annual outcomes
which demonstrated growth and maturity sum- data, not summaries of activities. Reports of county
marized in the Baldrige ADLIs schema. Leaders and combined state outcomes were generated from
set the tone by encouraging sharing among coun- third parties and distributed to LHDs (e.g., birth
ties and by internal, continuous recognition of certificate records, hospital emergency department
county accomplishments. reports, and national youth smoking surveys). LHDs
reviewed county outcomes, considered results of
Other Factors, Such as Social Responsibility PDCA cycles of learning, and then modified their
and Risk Management annual investment plans. Those plans were pre-
Public health stresses its responsibility to the sented to county officials and partners, recognizing
public including its consideration of societal well- success and noting changes to address shortfalls.
being and benefit. Public health science is clear Addressing this organizational and personal sense
that social and environmental contexts are deter- of risk became an important factor in the manage-
minants of a person’s health.12 TDH’s adoption ment strategy of TDH.
of the Baldrige framework promoted the view A continuing challenge for public health is to
of quality principles applied at dual levels of demonstrate and describe the effectiveness of popu-
improvement—daily work processes and long-term lation intervention programs that prevent something
community health.13 This dual approach helped bad from happening. This challenge is multiplied
staff to embrace both the importance of account- when implementing a program across 95 counties
ability for daily workflow and the broader social with different levels of human resources and com-
responsibly to improve a population’s health. TTSP munity beliefs about tobacco use. TTSP worked to
provided new funding and autonomy for LHDs to demonstrate primary prevention strategies and docu-
expand efforts to address smoking in three target ment results with a defined evaluation scheme using
priority populations. While accepting responsibility external data. TTSP helped address the human side of
for creating annual county TTSP investment plans, quality, evidenced by statewide adoption of PI tools,

www.asq.org/pub/jqp 9
 changed work processes and success in bringing
about needed changes to help reduce smoking and
its negative health impacts in the state.
Discussion
Counties were surveyed about perceptions of the
value of utilizing the Baldrige framework with TTSP
to guide performance improvement. Ninety-five
counties responded about the amount of impact
TTSP had on county health departments by ranking
the impact of each of the seven Baldrige categories
using a five-point Likert scale, (5 being the most and
1 the least impactful). Results indicated leadership
(2.7); measurement, analysis and knowledge man-
agement (2.6); results (2.5); strategic planning (2.4);
and customer focus and engagement (2.3) had the
greatest impact. Process and systems focus (2.0) and
workforce engagement (1.9) were ranked lower. The
three most impactful categories indicate acknowl-
edgement of their value to counties in aligning
work systems changes. The two lower-rated catego-
ries, implementation of concurrent department-wide
TDH Baldrige and new state individual performance
assessment systems, may have been seen as more
influential in promoting change than TTSP.
To help prevent disease associated with smoking,
TDH tested the Baldrige framework as a perfor-
mance-management system with TTSP. LHDs also
applied cycles of learning, following the PDCA
model, to improve its planning, investments, opera-
tions, and performance over time. Furthermore,
TTSP used the Baldrige ADLI tool, which evaluates
work process maturity to enhance this system (a
fuller description of this schema is provided in the
online supplement). TTSP represents the first sys-
tem-wide, fully deployed effort to achieve primary
prevention using performance-management tools
and concepts through the Baldrige framework.
More Online
A supplemental table, “TTSP New Program Methods With
Lessons Learned,” is included online. Furthermore, additional
details on how this program measured the maturity of its
performance improvement process, based on the Baldrige tool,
are discussed in the second supplemental online article at
www.asq.org/pub/jqp.
References
1. United Health Foundation, “America’s Health
Rankings Annual Report 2017,” https://assets.
americashealthrankings.org/app/uploads/ahrannual17_
complete-121817.pdf.
10 The Journal for Quality & Participation April 2019
2. John D. Dreyzehner, “The Big 4: Using Primary
Prevention to Drive Population Health,” Journal Public
Health Management Practice, January/February 2017,
pp. 1-2.
3. John D. Dreyzehner and Bruce Behringer, “Choosing
Stones, Moving Mountains: Performance Excellence,
Primary Prevention and Culture Change in a State
Health Department,” Journal of Public Health Management
and Practice, 2018, Volume Publish Ahead of Print -
Issue - p doi: 10.1097/PHH.0000000000000890.
4. National Institute of Standards and Technology,
Baldrige Excellence Framework (Health Care): A Systems
Approach to Improving Your Organization’s Performance
(2017-18), U.S. Department of Commerce, pp. 30-38
and 43-44.
5. ASQ, “Learn About Quality, Plan-Do-Check-Act
(PDCA) Cycle,” http://asq.org/learn-about-quality/proj-
ect-planning-tools/overview/pdca-cycle.html.
6. Levinson A. William and Rerick A. Raymond, Lean
Enterprise: A Synergistic Approach to Minimizing Waste,
ASQ Quality Press, 2002, pp. xiii-xiv, 38.
7. Tracy O’Rourke, “Rapid Improvement Event
(aka Kaizen),” https://goleansixsigma.com/
rapid-improvement-event-aka-kaizen/.
8. ASQ, “5 Whys,” http://asqservicequality.org/
glossary/5-whys/.
9. Micky Roberts, David Reagan, and Bruce Behringer,
“A Public Health Performance Excellence Improvement
Strategy: Diffusion and Adoption of the Baldrige
Framework Within Tennessee Department of Health,”
Journal of Public Health Management and Practice,
November 2018, Publish Ahead of Print - Issue - p doi:
10.1097/PHH.0000000000000926.
10. Karl Umble, David Steffen, Janet Porter, Delesha
Miller, Kelley Hummer-McLaughlin, Amy Lowman, and
Susan Zelt, “The National Public Health Leadership
Institute: Evaluation of a Team-Based Approach to
Developing Collaborative Public Health Leaders,”
American Journal of Public Health, April 2005, pp. 641-644.
11. Bruce Behringer, Micky Roberts, and Chelsea Ridley,
“Promoting Statewide Quality Improvement in Tobacco
Use Prevention Through Longitudinal Health Promotion
Training for Tennessee County Health Departments,”
Pedagogy in Health Promotion, April 2018, https://doi.
org/10.1177/2373379918760636.
12. CDC, “TheCommunityGuide,” https://www.thecom-
munityguide.org/about/about-community-guide.
13. National Institute of Standards and Technology,
Baldrige Excellence Framework (Health Care): A Systems
Approach to Improving Your Organization’s Performance
(2014-15), U.S. Department of Commerce, pp. 1.
 Micky Roberts Laura Conner
Micky Roberts is deputy assistant commissioner, Division Laura Conner is county director for Roane and Morgan
of Policy, Planning and Assessment and Director Office of counties. Conner has achieved master examiner and
Performance Management for the Tennessee Department applicant status for several years with the state alliance.
of Health. His duties include providing oversight for all Send an email to Laura.conner@tn.gov to learn more.
Baldrige staff examiner training and applications for all
95 county health departments in collaboration with the
state alliance of the Tennessee Center for Performance
Excellence. Roberts served as director of that program, as
well as a Baldrige examiner from 2012-18. He also is a
Master Certified Health Education Specialist through the
National Commission for Health Education Credentialing.
For more information on this article and the initiative it Michael Railling
describes, contact him at Micky.roberts2@icloud.com.
Michael Railling is county director for Cannon, DeKalb, and
Smith counties. He has worked with the state alliance as
both an examiner and applicant in recent years. Railling
also is an ASQ Certified Six Sigma Black Belt (SSBB).
Contact Railling by email at Michael.Railling@tn.gov.

Caroline
Chinouth Hurt
Caroline Chinouth Hurt is county director for Carter and
Johnson County Health Departments, and she has served
as both an examiner and applicant throughout multiple
years with the state alliance. Chinouth Hurt is a Board Bruce Behringer
Certified Baldrige examiner with the Tennessee Center
for Performance Excellence. Contact her via email at Bruce Behringer is deputy commissioner emeritus for
Caroline.Hurt@tn.gov. the Tennessee Department of Health. He has served as
the deputy health commissioner for continuous quality
improvement, which included development of the Office
of Performance Management and utilization of tobacco
settlement funds. Behringer previously served as associate
vice president at East Tennessee State University for
20 years. He has authored many articles related to
community development and public health. His email
address is behr320@hotmail.com.
Emily Rushing
Emily Rushing county director for Henderson, Carroll, and
Chester counties. She has served multiple times as both an
examiner and applicant with the state alliance. Rushing
is a Board Certified Baldrige examiner with the Tennessee
Center for Performance Excellence. For more information,
send an email to Emily.Rushing@tn.gov.

www.asq.org/pub/jqp 11