A Public Health Performance Excellence Improvement Strategy: Diffusion and Adoption of the Baldrige Framework Within Tennessee Department of Health.

In 2011, Tennessee was faced with poor state health rankings with newly elected officials promoting customer-focused government. To refocus, the Tennessee Department of Health chose a multiyear plan to adopt, diffuse, and integrate the Malcolm Baldrige Performance Excellence framework. Senior leaders changed the organizational culture using participatory strategic planning coupled with introduction of performance improvement initially led by departmental staff who volunteered for training by the state Baldrige affiliate. New tools and processes were diffused across the department's central and regional offices and county health departments. Departmental units documented performance improvement through hundreds of internal projects and more than 100 innovation-driven Baldrige achievement awards. Over time, performance improvement approaches were integrated into existing departmental programs and new initiatives, leading to additional successful process changes and population health improvements. The department's approach included multiple steps: adopt Baldrige Performance Excellence as means to promote culture change with a goal of improved organizational and population health performance; use the visual Baldrige framework and its categories to underscore inclusiveness, comprehensiveness, and synergies of desired change; choose, invest in, and implement multiple evidence-based management strategies to support culture change toward improvement; and continuously evaluate outcomes, linked to required reports to suppliers (governor and legislators) and customers (public, patients, and partners). The Baldrige Performance Excellence framework was found to be an effective approach to promote culture change through emphasizing improvement in a public health organization.

Fungal infections associated with contaminated methylprednisolone in Tennessee.

BACKGROUND: We investigated an outbreak of fungal infections of the central nervous system that occurred among patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy. METHODS: Case patients were defined as patients with fungal meningitis, posterior circulation stroke, spinal osteomyelitis, or epidural abscess that developed after epidural or paraspinal glucocorticoid injections. Clinical and procedure data were abstracted. A cohort analysis was performed. RESULTS: The median age of the 66 case patients was 69 years (range, 23 to 91). The median time from the last epidural glucocorticoid injection to symptom onset was 18 days (range, 0 to 56). Patients presented with meningitis alone (73%), the cauda equina syndrome or focal infection (15%), or posterior circulation stroke with or without meningitis (12%). Symptoms and signs included headache (in 73% of the patients), new or worsening back pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff neck (in 29%). The median cerebrospinal fluid white-cell count on the first lumbar puncture among patients who presented with meningitis, with or without stroke or focal infection, was 648 per cubic millimeter (range, 6 to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was 114 mg per deciliter (range, 29 to 440); and the glucose concentration was 44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to 6.7]). A total of 22 patients had laboratory confirmation of Exserohilum rostratum infection (21 patients) or Aspergillus fumigatus infection (1 patient). The risk of infection increased with exposure to lot 06292012@26, older vials, higher doses, multiple procedures, and translaminar approach to epidural glucocorticoid injection. Voriconazole was used to treat 61 patients (92%); 35 patients (53%) were also treated with liposomal amphotericin B. Eight patients (12%) died, seven of whom had stroke. CONCLUSIONS: We describe an outbreak of fungal meningitis after epidural or paraspinal glucocorticoid injection with methylprednisolone from a single compounding pharmacy. Rapid recognition of illness and prompt initiation of therapy are important to prevent complications. (Funded by the Tennessee Department of Health and the Centers for Disease Control and Prevention.).