Maternal and Child Health Bureau

Needs Assessments to Strategic Action

June 6 - 7, 2006

The MCH Assessment, Planning and Evaluation Cycle:

Context and Purpose

DONNA PETERSEN: Happy to be here. This is as Cassie said the last of four workshops is the largest group we’ve had by far so, we’re going have to do a little bit of adjusting on the time because we do a lot of small group work because that’s where you really learn and get the most out of these kind of sessions and then we need to hear back from all of you. So, we’ll make some adjustments as we go. This will be hard for you guys recording but we do want to go around and let everyone introduce themselves. So, we know who’s here and what states and what programs and again, it’s a large group. So, just your name and rank, serial number. Your name, your state, and your program just so we know who folks are. So, let’s start over here in the corner.

GRETCHEN: Gretchen (Inaudible), I’m from Iowa. (Inaudible).

MELISSA ELLIS: I’m Melissa Ellis (Inaudible)

DONNA PETERSEN: Can you hear her?

MELISSA ELLIS: I’m Melissa Ellis, I’m from Iowa and I’m a program trainer for Maternal and Child Health.

DONNA PETERSEN: Great.

BERTH COLE: I’m Berth Cole and I’m with Special Needs Program with Iowa Corp (Inaudible).

ROBERTA LACARTHY: Roberta Lacarthy from the Texas Department State Health Services and The Children’s Special Health Care Needs Program and Assisting Development.

MICHELLE BRADLEY: I’m Michelle Bradley from (Inaudible), New York (inaudible) Health Department.

MICHAEL GRATSKY: Good morning I’m Michael Gratsky and I’m with New York State Department of Health with the Service of Community Health and I work on the needs assessment.

DONNA PETERSEN: Great.

SUSAN BERKER: Susan Berker, I’m from Austin, Texas and I’m working with the type of bioresearch team (Inaudible).

JOHN GOURLEY: I’m John Gourley from Minnesota and I specialized in (inaudible)

MARCY BRACKIS: I’m Marcy Brackis from Glendale and I’m supervising (inaudible)

MELISSA DAVIS: Melissa Davis from Connecticut. Connecticut (inaudible) Director and section chief (inaudible)

DONNA PETERSEN: Welcome.

ED CRUE: Good morning. I’m Ed Crue, I’m from Indiana. I’m the director for Maternal and Children’s Special Health Care.

BOB: I’m Bob (inaudible) and I’m from Nebraska (Inaudible).

RAY MACLAINE: Ray MacLaine, from Nebraska. I administer the top five block program working with the contracts and sub grants involving the communities as well as internal out patients within our states.

PAULY YORK: I’m Pauly York, I’m an Administrator of Office of Family Health (inaudible) while completing services and regulating the crisis.

CANDICE: Good morning. I’m Candice from Internal (inaudible)

DONNA PETERSEN: Great. Go back in.

UNKNOWN SPEAKER: (Inaudible).

DONNA PETERSEN: Okay, way in the back.

RWANDA SANDERS: I’m Rwanda Sanders. I’m in a section that serves the patients what they deserve.

DONNA PETERSEN: Welcome

JAMIE THENON: Jamie Thenon, (inaudible) the Children with Special Health Care Needs worker.

MYLENE MYER: I’m Mylene Myer, I’m the director of Children and Family Section. at the Bureau for Children and Family (inaudible)

BEVERLY ENGLISH: Good morning. Beverly English, I’m from Illinois. I’m Chief of Maternal (Inaudible).

GARY PARKINSON: Good morning I’m Gary Parkinson, I’m the chief of the Bureau of Special Healthcare within the Missouri Department of Health Services.

SUSAN BERRY: I’m Susan Berry and I’m the Medical (inaudible) for Corporate Special Healthcare (inaudible)

GERALDINE MCGARTH: I’m Geraldine Garth, Louisiana Child Healthcare (Inaudible).

CLINT MILLER: Hi I’m Clint Miller, I’m the division director of Community and Public Health, which has all the community programs including the Missouri Public Health and Senior Services.

NANCY HELLEGER: Hi I’m Nancy Helleger, from Arkansas, (Inaudible) with Children With Special Healthcare needs.

DICK NUGEW: I’m Dick Nugew with help (Inaudible). My telephone number is 501.

DONNA PETERSEN: From Oklahoma.

KAREN HILTON: Karen Hilton from Oklahoma, Children Special Healthcare and Correction.

DICK LAWRENCE: I’m Dick Lawrence, Oklahoma State Health Department and Recreational Assessment.

SUSSY LYNCH: Sussy Lynch, chief of Maternal Child Health Services (inaudible)

LIZ ROCK: Hi I’m Liz Rock and I coordinate with (Inaudible).

JESSY SHARON: Good morning my name is Jessy Sharon and I’m also from Ohio, and I’m the acting chief of the Bureau of Child Healthcare Services (inaudible).

JERI CLARKE: I’m Jeri Clarke, I’m from Illinois Children Special Healthcare Program.

SUSAN NUETER: Hi, I’m Susan Nueter, from Divisional Public Healthcare (inaudible)

LINDA HALE: I’m Linda Hale. I’m a (inaudible).

DONNA PETERSEN: Wonderful. What a handsome group. Delighted that you’re all here. This is a–-we truly have the whole middle of the country, I think here. I think we have 16 states represented including our guests from New York and Connecticut, we’re delighted to welcome you. Folks from New Jersey, were down in region four, and that was actually nice. You know, it’s convenient to group by regions and we have some things in common but sometimes we can learn from folks from other parts of the country. We had some good discussion in Fort Lauderdale, we look forward to today, as we’ve said already, we will be presenting some information to you but we’re going to give you plenty of opportunities to share with us and share with each other. These sessions I think are most fruitful when we work together, you’re all out there doing the–-doing the good work and have things to share with your colleagues here. We will focus on how you move forward from the comprehensive needs assessment that you’ve just completed about a year ago. How do we adapt and embrace a planning process that will be the focus of a lot of our discussion. What are the challenges that you all face and acting on new priorities and ultimately, we’re going to help you gain some confidence in the process of managing change, which is what this is all about. And it was interesting reading your homework submissions and this was true, I think pretty much across the country that there has been a true evolution in the way you conduct your needs assessments.

There was a tremendous increase in the extent to which, you used and engage stakeholders and other organizational partners and community partners and families of a huge leap forward from five years ago. I think that’s tremendous. But when you do that, when you engage abroad constituency then you also take on some –- some obligations and then that was also some of the challenges that you reflected that despite your pride and doing a great job, doing the true comprehensive, inclusive needs assessment, now you’re going to deal with all of these people. And how do we then keep these partnerships going? How do we engage in collaborative action? Now that we’ve done collaborative assessment and a little bit of priorities setting, how that we then move that agenda forward? And that’s part of the challenge that we’re going to talk about today.

So, we’re going to do today is review--just to put as in some contacts as whole MCH assessment planning, implementation, and evaluation process that we engaged in. We’re going to talk about some of the myths and realities of about priority setting and program planning. Then we’ll put you in some small groups to focus on some of the challenges that you faced. Then we’ll comeback and talk about how do we create new efforts and plans to follow those new efforts reflective of the priorities that we established from our needs assessment. Put you back in some small groups and then end the day talking about monitoring and evaluation, which is a hard way to end the day, but we’ll do our best to keep it lively for you. Then we’ll comeback tomorrow and focus the morning on the process of managing change, and I think you’ll enjoy that. That’s a fun session. Okay? Sound good?

All right, you’ve got copies of the slides in your notebook if you want to follow along, take some notes, there under the green tab I believe, in the front. All right. I like to start because I think it’s important to sort of remind us where we sit, though it’s interesting in this region and I’m familiar with the number of the states here, you’ve gone through some re-organizations, you’re perhaps split MCH may not be with Children with Special Needs, MCH may not be in one unit, you might be in a health department, you might be in something like a health department but perhaps not. And so, we have to remember that we are part of public health. We are part of the public health system, the public health mission to improve the lives of the populations that we serve. So, public health is not something that we do to people but something we do collectively with people to create those conditions, in which people have every opportunity to be healthy. And I’ve had the opportunity lately to do a lot of speaking to community groups with lay audiences about public health. And it’s interesting, because people don’t--you know, what’s public health? And the word public kind of trips us up sometimes because public has a connotation that isn’t necessarily positive. So people think about public housing, and public transportation wherein in fact, public health is more like a public good, and trying to help people understand that. When you ask people, “Would you prefer to be healthy or not healthy?” They look at you like you’re crazy, “Of course I want to be healthy. We all want to be healthy.” Well then, how do we translate that desire to be healthy and for our children to be healthy, and our parents, and our spouses, and our friends into public health actions that you can then implement on behalf of that public. That’s the challenge that we face. Now we know that maternal and child health is part of public health. Wherever you go in the world, you will find the maternal and child health component to whatever public health effort that country or state mounts. That it is in our national interests, it’s in everybody’s national interests, to assure the health of the children because they are our future. Now we say that, and you say, “Oh well, you don’t know just like in my state.” It’s sometimes hard to translate that message to policy makers and elected officials, but we know in our hearts it’s true, and most people when pressed will say, “Yes, I would prefer my children be healthy and grow up to be healthy adults.” People understand this.

Our focus is on populations, the entire population. All the women, all the children, all the youth, all the children special health their needs, all the families, everyone in your state is your responsibility. And you also have responsibility to try to do your best to focus on prevention, and again that’s a hard sell. It’s hard to get people excited about the things that didn’t happen. Though we certainly in our colleagues from Louisiana, and they didn’t know I was listening to them on the shuttle from the airport yesterday, talking about you know, you have to be careful, you know, I’m sure they have stories they can share with us about preparedness, and prevention, and anticipation. These are hard things to do even though you can intuitively and logically explain why we would wish to prevent bad outcomes, bad responses, bad disasters, it’s often hard to sell, but that is our emphasis. Our emphasis is on anticipation and prevention, early identification, early treatment. We are oriented toward communities. So, we set at the state level, you also at the state level but your orientation is at the level of the community. How do I implement systems that work for families, and children, and whoever it is your focus on at the level of the community? How do we engage the community to provide the best supports and the services for the people that reside within that community? I mentioned systems. It’s part of our statutory mandate. It’s something that we sometimes have a hard time grasping ourselves against something difficult to explain to people, but with the very limited resources you have, and a number of you spoke about challenges you’ve faced, and small comfort but these are the challenges you folks colleagues shared across the country. Limited money, limited staff, not enough time, not enough information, not enough political will, all the things that we cope with. How we then manage those other entities to create systems is how we can help achieve success. Because we can’t do it all on our own. We simply don’t have the capacity to do all the things that we would wish to do. So, we’ve got to work at the level of the system and find those pressure points or those opportunities where we can make -- perhaps, a small change over here and create a big effect. Okay?

Our role is to be the leader for this population, for the health needs of this population. We’re the only ones that have this overarching responsibility. All those other programs that we work with that provide pieces of that system don’t have this broad responsibility, this idea that you are responsible for assuring the health of all the women, children, family, children’s with special needs, youth in your state is a tremendous responsibility, and you ‘re the only one that has it. So, you have to exercise it to the extent that you can with every opportunity that presents itself to you. That’s how we kind of frame what we’re talking about here. An MCH public health perspective. Now, who read the Institute of Medicine Report, the Future of Public Health back in 1988? You all weren’t around, then you’re too young. Back in the third grade, we all read the Institute of Medicine -- wouldn’t it be nice if all the third graders read the Future of Public -- we might change the world that way. Okay. So, you remember, perhaps, those of you that are just old enough to remember that. That the Institute of Medicine really looked at public health in this country in the late 80s, and said, “We don’t have a public health system in this country. It’s a mess. We don’t agree on what it is. We don’t agree on what it’s supposed to do. We don’t agree on how to be organized. We have state, local, sometimes, no local, you know, --. It’s a mess,” and so, they articulated what is public health, and the way I defined it for you is directly from that report, “What we do collectively to create conditions in which people can be healthy,” and then they articulated the three core functions of public health, that I hope you recite before you go to bed every night, when you wake up in the morning.

Assessment, policy development and assurance, and we’re going to talk about these a little bit today, but it was a way of framing what public health is and what it’s not. It makes it clear that we’re about the population, I think. We’re out there assessing those conditions that affect people’s health. We are then working to develop policies and programs and garner the resources to address those things that affect people’s health, either shoring up those that are positive or working to reduce those that aren’t and then assuring that those things are in place. So, it’s a different kind of focus. It’s different from the Medicaid program. It’s different from clinical healthcare. It’s a very broad-focus. Well, you know, they -- reports like this come out, and everyone gets exercise, then folks from the federal government went around to all the states. I don’t know if you remember that. You know, they come in with their entourage, and they present this to us. Now, for those all of us in the MCH though, this wasn’t terribly new. This is kind of what we’ve doing all along, and it was one of those great moments which happen at some periodic interval where the rest of public health discovers something that we’ve been doing for years, and you can kind of sit in the back and sigh, or you can say, “Well, I’ll take the lead on that because I know what I’m doing,” and there are a number of states that took that opportunity to do that. Well, a lot of folks got together and said, “Well, that was a nice report, and we like those core functions, but they’re not explicit enough, and we need to do a better job of explaining what it is that public health does.” So, the State and Territorial Health Officials, and the National Association of City and County Health Officials, and the American Public Health Association, the CDC, and all these guys got together and came up with this 10 – the list of 10 essential services – 10 essential public health services, and of course, in typical fashion, they weren’t sort of MCH-ish enough for us, so we MCH-izied them for ourselves. Halle Grayson and folks at some should bet that time. MCH-ized the 10 essential services, and there’s a copy in the back of your notebook in case you’ve misplaced your provisional copy, because they’re nice. They’re a nice list to kind of remind us of those activities that we need to be engaging in in order to achieve our goal of assuring the health of all the women and children in our state. So, this assessment function plays out in the first two. We need to be assessing and monitoring the health of mothers and children and families. We need to be diagnosing and investigating health problems and hazards. We need to be informing and educating the public and families. We need to be mobilizing those partnerships, again, at the community level. That’s where our orientation is. We need to provide the leadership that’s necessary for setting priorities, planning, developing policy to support what we want to happen in communities, promote and enforce legal requirements, link women and children to services, and we’ll talk a little bit later about the extent to which we are more or less engaged in direct services. Some of us got out of that business. Others of us are moving back into it. Others of us never left it.

Assuring the capacity and competency of the workforce evaluation, we’re going to talk about today and the support of research, which I love speaking to public health audiences. They always shake their heads and say, “We don’t do research. That’s what you and academia do.” But the fact of the matter is, every time you try something new and we’re going to talk about that today. You did some needs assessments. You set some priorities. You’re going to be trying something new. You’re engaging in research, if you will. You didn’t write a grant to NIH. You didn’t derive a hypothesis but you are going to show us that this works or doesn’t work. And the extent to which you can share that knowledge with the rest of us helps advance all of us. So, it’s like 59 natural experiments. You know, you’re all out there responding to your local needs. You’re all trying new things. We’ve got to do a better job of sharing that and learning from each other so that we don’t have to make the same mistakes or reinvent wheels, or those things. And I’m going to exhort you to do more of that as we go through. Okay? The ten essential services.

Now, we know in MCH, we are part of public health. We share that mission, that population focus prevention, all of those things but we also have sort of intensive responsibility. We’ve got broad public health responsibility but then we’ve got sort of intensive responsibility for those things that we can’t make happen anywhere else. So, we have this sort of dual role of at once being responsible for the entire system and then we have programs we have to run. We have projects that we’re responsible for. We have tasks and committees and things that we have to do that are very focused and a lot of our staff are hired for focused programs and projects but at the same time, we have this broad responsibility. So, it can be really, really challenging because in some ways, you’re responsible for everything that goes on whether it’s across the public health sector or all those other agencies and good golly, you know, I’ve only got three people in this office and we’re trying to do the lead program and the prenatal program and transition kids with special needs and I’m supposed to be responsible for all of this stuff. So, the extent to which we can master that complexity, have people that are skilled and talented in certain areas of expertise but then also utilize their broad perspective to kind of champion the whole system and advocate for what we need to have happen is a task that we must take on here. So, we know that we’ve got this huge responsibility. We have very few resources and they’re dwindling for most of us. I don’t think anyone said they had more money to play with. This was sort of a resounding theme, you know. We keep getting cut. We have fewer resources. We lose staff. We can’t retain them. We can’t hire, you know, all of these challenges that you face. So, that just means that we got to be as smart as we can possibly be. That we’ve got to choose the best strategies with the limited resources that we have, which means that we got to pay attention to the way we plan and the decisions that we make in order to be as successful as we can be.

Now, you’ve seen this or something like it somewhere in your lives. No magic here. This is just one way of depicting a planning process. There are others you may have one you like more. You might have logic models that you like. It doesn’t matter. The point is just to illustrate a couple things. One is that this is an ongoing process. We don’t have the luxury of stopping everything. It’s “Okay, everybody stop. We’re going to plan and when we’re done, then we’ll implement the plan and then you can all start again.” Things are happening while you’re planning and we planned. We do have sort of natural cycles; you plan for the legislative session; and you plan for the budget hearings in your agency; and you plan around the block grant. But the fact of the matter is, those are sort of points in time. You’re planning all the time. You just did a five-year needs assessment but then that you’re not done assessing needs. You’re assessing needs all the time. You’re always taking in information and you’re planning and you’re coming up with goals and objectives and you’re implementing and you’re adjusting and you’re planning for evaluation and it’s an ongoing process. Okay? Just a simple illustration of what you’ve been going through the past couple of years.

Now, in this model, we begin with a mandate on the top or a problem-needs analysis. You can kind of comment at any point. But often, it’s a mandate, either one you impose on yourselves, like the priority-setting process you just went through, or one that comes to you from the outside. And a number of you, in your homework, talked about competing priorities. You know, I’ve got mine, but the health officer has hers, and the governor has his, and the legislature has theirs, and you know, on and on and on. And often, we’re in the position of responding to an external mandate that we didn’t generate, we wouldn’t have suggested, but you’ve got it now. Right? The legislature comes up with something. The governor’s wife goes somewhere and comes back with the next great idea. Right? Please don’t go anywhere. Don’t go to that meeting. And it’s hard just--you can’t say no to those things. You have to try to adapt and respond. So, you know, external mandate requires the same level of planning. You can’t waste your resources. You got to do the best you can. So, we can start with those kind of mandates or we can start with your own needs assessment results.

Now again, you have just each completed a very comprehensive, very thorough, very detailed, very inclusive assessment of needs across the entire spectrum of the maternal child health population across all the responsibilities of the essential services of the pyramid, all those things, very, very complex. And you did that by using a couple of tools or engaging in a couple of tasks. You looked at the data sources you have available. You engaged stakeholders and heard what they had to say and listened to them. From those needs then, you then thought about solutions, what strategies do we have available to address those needs. And then from all of that, you settled on a set of priorities. And as we said before, you can see it when you read everyone’s priorities. And I hope we’re going to get everyone’s homework, because it’s really interesting to see what states came up with.

And you can see what happens when you engage a broad group of stakeholders and, you know, the--a stakeholder is someone with a stake in something. They might have a stake in children, but typically, they have a stake in bicycle helmets. Right? So, you engage all these people, and they try to be honest about it and look at all your data with you and hear what everyone says. But at the end of the day, the bike helmet lady has to go back to the bike helmet association and say, “I got bike helmets on the list.” Right? So, what happens is these priorities become--because the only way you satisfy the bike helmet lady and Mothers Against Drunk Drivers and the domestic violence is to say, “We’re going to reduce injuries.” Right? So these priorities then become perhaps more diffuse than we would like them to be but you did come up with a set of priorities from those processes.

Now remember that you did this. It’s an ongoing cycle. You assess problems, needs. Perhaps you looked at assets and strengths. You thought about solutions. Now you’re going to have to implement those solutions. You’re going to have to allocate resources in order to make that happen. We want you to evaluate what you’ve done. You’ve got to monitor your performance because you’ve got performance measures to take into account. And then all that data feeds back into your ongoing assessment. So, you know, regardless of how you do this, regardless of the challenges, this is a cycle. It doesn’t change. It’s what it is. And we know this is definition of assessment from the Institute of Medicine Report, that same report, that it is the responsibility of every public health agency, and this includes you. To regularly and systematically collect, assemble, analyze and communicate those data back to the community. It’s an ongoing engaged process. It’s complicated. But again, we know this because we’ve been doing this since 1912 when the Children’s Bureau was first established, with the express purpose of investigating and reporting on all matters relating to child life and welfare among all our people. I think it’s what the language said.

This responsibility that’s in Title Five, to assure the health of all mothers and children, requires that you do this. It doesn’t, you know, regardless of whether it’s a core public health function or in the law. You have to do this anyway. You can’t perform that function. You can’t achieve that goal if you don’t know what’s going on that affects the health of women and children and families in your state. So you’re doing this all the time. You’re looking at trends and populations; a number of you mentioned that. Population shifts are affecting what you do. Health status indicators, risk factors, the attributes of the system, of healthcare and the availability and accessibility of services, and what quality are they of. Because we know that for this population, there has to be access to quality healthcare services, while there also has to be efforts to shore up the whole public health system, create those conditions in which people can be healthy. So you’re doing this all the time. We need to do this to direct our decisions most effectively and most appropriately. We got to make the best decisions that we can make. OK.

Needs assessment is a fundamental part of any program planning activity. It’s about change. And those of you that were with us two years ago, we’ve spent a lot of time talking about, if you don’t--if you’re not willing to change, if you’re not willing to consider changing, then you really shouldn’t be doing this. Now of course, you have to do it by law but you have to get your head around the fact, that doing this means you’re going to have to change something. It is highly unlikely, that you’re going to do a needs assessment and find that you have no needs or that they’re all being met. I mean, it would be marvelous if that were true but that’s not what’s happening out there. Things change all the time, new things emerge, things go away, agencies change, personnel changes, all these things change. And so, the whole point here is that the very act of saying, “I’m going to be assessing needs, I’m going to be making decisions, I’m going to be setting priorities,” means you’re going to have to change. Things are going to change. And that’s okay because that’s what strategic planning is all about. And when you responded on your technical assistance request forms and said, whatever you said, you know, “We need some help, because it’s hard.” Change is really hard. People don’t like change.

You’re going to be engaged in a strategic planning. You’re going to be setting some directions. You’re going to be changing your direction and perhaps going to change some of your efforts. You might change your staffing, you might change your resources, either what comes in or what goes out, and how they go out. You might be changing outcomes. You might be changing lives. That’s what you’re trying to do here. You’re trying to improve the lives of the children and families in your state.

Ongoing processes, the Five-Year Needs Assessment--again, it’s a point in time, and it’s kind of a nice point in time because it forces you to sort of, stop and at that point in time at least say, “All right, let’s kind of re-look at where we are. Let’s re-engage folks. Let’s look at our data systems. Let’s figure out if we’ve got to change things.” And perhaps, we might identify the need to do other needs assessments because often what you learn through these processes is things that your data systems don’t tell you because you’re not collecting data on that because you didn’t know it was a problem. It only just emerged or you’re not allowed to collect data on that politically or whatever the reason is. So, maybe part of the strategy is, “I need to know more.” Maybe the strategy for child obesity prevention is, “I need to know more because I don’t necessarily know how to act.” I can see that it’s a problem. In fact, I don’t the data they show me. It’s, I just have to go to the mall and I can see it’s a problem. But what do I do about it? That’s not so easy. So, maybe I need to gather more data. Maybe I need to follow Arkansas’ lead and start recording, collecting, and recording BMIs on all children. Maybe I need to be doing an assessment of what the education policy is in the schools. Maybe I need to be figuring out, you know, how do parents feed their children? How do people eat? How do they – and you know, you see this all the time and it’s funny how you’ve been seeing it all along but now you’re acutely aware of it, you know. Do you watch what eat people now when you’re out? Do you watch what they put in their grocery carts? I mean it’s terrible. I can’t go to the grocery store. I’m looking at everybody’s carts. And I’m looking at what the kids are eating and, you know, you look at people and think, “God, what, you know, do you not know any better?” Well, maybe they don’t. Maybe no one ever explained it or maybe they’re not making the connection, or maybe that it’s too hard. So, how do we–-it might be that we need to know more. Okay?

We know this population is a dynamic population. I told this story a couple of sessions ago and I don’t remember the guy’s name because I blocked it out of my mind but he was the HRSA administrator at some point. And I was at a meeting where he was, and he said, “Do we really have to keep funding MCH? Aren’t you people done?” And I’m like, “No, because right down the street here at the local hospital, there’s babies being born and we don’t know what challenges they’re going to face.” We don’t know what the world’s going to be like. We’re never done. We’re never done. But you know, but in his mind, they’d been funding this for 50, 60 years and we should be done by now. Okay.

We know this population is ever changing. We know that we have to be good stewards of the trust that’s been placed in us. We’re public servants. We rely on public dollars to do our work. And we know we’ve got to address priorities within very limited resources. So, how do we do that most effectively? Okay.

That Five-Year Needs Assessment was a critical point in time. Again, we’ve seen it evolve tremendously from 1990, I think, when the first round after ’89. I don’t remember what year we did it, but we all kind of were scrambling and kind of throwing things together. And at that time, and if you have no time someday, which you never will, but if you go back and look at some of those block grant applications and look at the needs assessments people did, and then the plan they described. They were almost virtually disconnected. Because who had any ability to suddenly say, “Oh well, gee, I didn’t know we had those needs and now I’m going to change my whole program.” I mean, it was a really daunting task. We’ve moved a tremendous distance from then. Okay..

And again, there were key elements that you utilized in that needs assessment process that you’re going to want to continue, because these are ongoing processes and you don’t want to have to start them off all over again. The first thing you did was you engaged stakeholders, and again, you all did this well and you were proud of it. We’re going to talk about why it’s important to keep that up.

You utilized the scientific knowledge-base to the extent that it’s out there for you to utilize but you used it. You recognize the politics of MCH. Needs reflect the values of your constituency. They’re not a number. They’re what people care about, and you knew that, and you incorporated that. You thought about solutions. You identified priorities. You established performance measures.

Stakeholders were important in the needs-assessment process. They continue to be important as you develop and implement your plans. Why? Because they can help you shape what you’re doing, build awareness of what you’re doing, build acceptance for what you’re doing, advocate for what you’re doing, and support your overall program. These are ambassadors for you. If you think of them like, you know, you can think of them as, you know, these are thorns in my side, or these are ambassadors for me. These people represent constituencies that are concerned about what we do. They’re concerned about how we’re changing that’s why they wanted to be on the committee, because they knew this was about change, and they wanted to know what the change was. But if you can engage them and keep them engaged, they can be tremendously helpful to you. Let them go explain what you’re doing. Let them explain that what you’re doing is for all of these reasons. Let them go to the legislature, either with you or when you can’t and we’ll talk about that a little bit too. There’s times when you can’t go. So, who’s voicing your point of view? Your stakeholders can do that for you.

How many of you have formal advisory committees? So, some but not all. Sort of, you know, again, it’s like, sometimes, these can become unwieldy but it’s sometimes helpful to have some kind of an advisory group that, you know, you have rules about how they get on and off, and what their duties are, but can really help you engage people in your process, buys you some good will, can help you address opposition. I mean, sometimes, you bring them on to your committee because you try to engage them and work with them directly, and it helps legitimize everything you’re doing. You know the past, and it’s been now at least 10, 15 years, where the perception portrayed by the media, you know, it’s like all of the government is bad. You know, big government is bad. Public sector is bad. You know, and you’re part of this. That’s what I was saying before when people think public, they think bad, things I don’t want to ever have to utilize, you know. I don’t ever want to have to use public transportation. I don’t ever want to have to use a public bathroom, for crying out loud. You know, and your part of the government; the government’s bad. You know, it’s hard for you to do what you do and have the kind of support that you need. It helps if you have a group outside of you to say, “Hey, this is not government. This is health. This is in your best interest because you all want to be healthy. It’s what we do to ensure our future.” Let those people be those ambassadors for you.

You also use a scientific knowledge-based. You use the data that you had available. Now, remember, you know, the quality of what you do is very much related to the quality of the information that you have available, both to identify the needs, but in the future, to help you monitor what you’re doing, and evaluate your success. The data has to be of good quality, and those databases have to be maintained, and continue to provide you with the data that you need to have the information that you need to continue to act.

So, what did you learn from the needs assessment process? Are there data that you need that you’re not collecting now? Like heights and weights on kids? So, you could calculate the BMI. Do your databases give you what you need? Do you have an opportunity--a lot of the databases, like the behavioral risk factor surveillance system, or the youth risk behavior. So, you can add questions too. You know, are there things you need to know that you could add a question to an existing surveillance system? Do you need to develop new systems? You know, did you uncover some huge problem in your state that you have no information, none at all, and you need the ability to collect it? Do you have the capacity to improve the quality of your data and analyze it effectively?

It’s wonderful to see the number of MCH epidemiologists in these states. And again, that’s a huge change from where we were 15 years ago. You know, these people didn’t exist, and you didn’t have that kind of capacity, now you do. So, you want to maintain it, you want to make sure they’ve got what they need to do their job. Do you have what you need to monitor what you’re doing and assess your performance? And are you communicating your data routinely to your internal partners, to your stakeholders, to elected officials? Are you keeping these issues in the public’s mind? And part of that is continuing to put out the data. We’ll talk a little bit later on this one, you know, are you giving the data back to the people who collect it for you? Because if you don’t, what incentive do they have to fill it out properly? And if you think of–is there anything more tedious than filling out a data form or entering stuff in the computer and if nobody ever comes back? “Oh, heck I’ll just roll those in my trunk and I’ll get to it next week or maybe I won’t”. Okay.

You want to be mindful of your data: where’s it coming from, where’s it going, how’s it getting utilized? You set priorities. Maybe you need to revisit them. You know, you set them but they’re not set in stone. Cassie will tell you, “You can modify them as you go because you’re going to keep learning.” As you plan and implement and engage in this change process, you’re going to continue to learn and you might be able to modify them. You might want to modify them. Hopefully, you use some kind of system–to think about priorities this was developed by the CDC (inaudible) that whole gaggle of public health folks who do this kind of stuff, where they suggested that, when you’re setting priorities you need to look at how many people are affected, to what level of severity, is there an intervention available, does it work, can you afford it? And then, again this is critical. This is why you’re engaged stakeholders. Does the community perceive that this is a problem? Because if they don’t, they’re not going to pay any attention to what you’re trying to do about it. They have to recognize the problem and they have to agree that the solution you proposed is something they can accept. And without that, all the data in the world–if your data is screaming at you, that something is a problem. If these two things aren’t there, you’re wasting your time. People have to agree it’s a problem and accept the solution that you proposed. And that’s why it’s so important to engage them in the process. I love this, is it legal?

We all have dreams, right? Fantasies are what you really want to do, if I could only, Okay? Is it legal? What political issues are related? Either to the problem or to the solution and we know in maternal and child health, we got the bunch of those political hot button issues, you know, all over the place. There’s no escape. We know there are political issues related to a lot of what we do. When you discover something through your assessment, you’re kind of thinking about this, you will often run into things that aren’t within your scope of responsibility. People will tell you about things that affect their health that they want somebody to do something about. It’s not your responsibility. But now that you know about it, because you’ve got that brought over our (inaudible) responsibility, you got to do something about it. Once you know it, you got to do something about it. That doesn’t mean you suddenly have to become the housing agency. But it means you need to be over with the housing agency saying, “Look, you know, I’m trying to promote people’s health. They’re telling me that they got lousy housing and–or they can’t get any at all because it’s not affordable or whatever it is. Can I work with you on this?” And lastly, what are the resources that you have to do this? You can identify a serious problem, if you don’t know what to do about it. There’s very little point in making it a top priority because what will you do about it? Though we’re going to talk in a minute about other ways that you can address those kind of priorities. Like right now, I’m going to talk about it.

Those of you that were here a couple years ago may or may not remember this; we’ve had fun talking about this around the country. We came up with this idea–just remember two years ago, we were still talking about data and gathering and assessing and involving stakeholders and all of this. And then, we started talking about what do you do when you’ve got these groups and they’re recommending things to you, and they’re not recommending things to you that you’re mandated to do? That was sort of the first issue. It’s like well, you know, they’re not telling me to do newborn screening but I know I have to do newborn screening. Well, of course, you do. So, we came up with this idea of the sort of “B-list.” You know, there are things that you know you’re going to do that you may or may not want to put on your 10 priority lists but you know they’re priorities for you. Maintaining the integrity of those systems, continually upgrading the skills of the staff, looking at the research literature, those are all things that you’re going to do in your newborn screening program, regardless of any member of the public ever says they care about.

A-list are the things that the public talks about that your data reflect, you know, March of Dimes has a set of issues and, you know, United Cerebral Palsy and the child–Children’s Defense Fund, you know, they’ve all got their issues and that’s the kind of typical stuff and that’s what you’re debating and then, you know, will should it be more prenatal care, should it be postpartum depression, Okay, those kinds of things. But then, you’ve got these things that come up, like childhood obesity is a good example. Well, everyone’s talking about it but we don’t know enough about it to act on it. And so, you might have a C-list. And again, they might show up on your 10 priority list with a strategy that talks about gathering more data, or assembling a coalition, you know, engaging other partners to begin to think about it, or they may not show up on that list, but they’re on another list that you keep somewhere, either in your head or in your own agency where--all right, I can’t ignore methamphetamine because everybody brought it up. It’s not my issue. We don’t know what in the world we’re going to do about it, but I can’t just blow it off because it came up every time I went out into rural Arkansas or rural Missouri and it came up. So, I’m going to put it somewhere else. But I’m not going to lose it because people are very concerned. Two years ago, I’ve only got 10 priorities? I’ve got more than 10 programs. I got 15 programs. How do I only have 10 priorities? Well, you know, there’s other ways to utilize that information when you’re thinking about planning. Okay?

Now, hopefully, when you came up with your priorities, you thought about solutions. Because again, it’s really not, you know, and again the solution can be we need to learn more. That can be a reasonable solution. But hopefully, you thought about solutions, so that you don’t just say, “Oh, yeah, we’re going to take on the meth problem.” But put that at the top of the list. Well, because now you’re sitting here, it’s obvious you got to do something about it. So hopefully, you thought about that before you put something out there on the–up there on that list. And again, even if you did that, you came up with a priority. You came up with something. You thought you could make some improvement in it. You still need to figure out what’s the best strategy to move forward. You know, coming up with something two years ago or a year ago, the world may have changed by now. And when you think about solutions, we’re guilty of this. Our stakeholders are guilty of this. People always think that if there were only more of them or more of what they do, then we would solve this problem. Well, we got to think beyond that. We got to be willing to think of other solutions than what we’ve been doing. Okay.

So, we can go back to those other functions. We can think about policy solutions, broader assurance solutions, you’ve got the definitions. You know what they are. And again, as I said, you will learn things, through a comprehensive needs assessment that aren’t within your scope of responsibilities, you will. Leading in policy development, that policy development function includes going to the people responsible for those programs and advocating with them for appropriate levels of change. If that’s what’s affecting your population, or if it’s housing, you know, you can provide prenatal care till the cows come home, but if they go home to infested dangerous toxic environment, then you’ve not solved the problem and you perhaps wasted your time and your resources. People will talk about things like crime that comes up all the time. They’re worried about education. They’re worried about environmental issues. They’re worried jobs or worried about transportation--these are not your issues, but they affect the health of the families in your community. Okay?

So again, you’ve got to get that to those other people and we spent some time talking at the last session about the challenge of having other agencies recognize your priorities. I’m sorry, I keep hitting that--you know, you’ve come up with these priorities and they may or may not have been involved, or they may not remember they were involved, or the staff has all changed because they turn over all the time. But it’s important to figure out, you know, all right, I did this broad needs assessment. It was population-based. This is what the people are saying. This is what the data tells me. Now, I’ve got to go and find other partner agencies who are responsible for these things and we talked about last time, that part of your job is to figure out who should take the lead on an issue. And sometimes, that’s obvious because it’s not your issue. It’s somebody else’s issue, but how do you convince them to do that or maybe it’s a truly shared issue, and maybe you have to give up. You know, I don’t have to run it as long as it gets run.

But again, I got to get other people motivated to do that, to take that on and that’s a difficult task to do. Again, the extent to which you can engage them early and keep them engaged, and I know the personnel changes all the time. That used to be one of my great frustrations that, you know, you finally established your relationship with someone in the Medicaid Agency or the Substance Abuse, and then they leave and you have to start all over again. And the new person might not, you know, the former person kind of shared your philosophy. They were gung-ho and the next person comes in could care less. That’s the challenge. We--and we always have to face that. Part of it is trying to figure out, you know, I need this program involved and if it’s not you, it has to be the next person. Assurance, you know the definition there. We know we have to set targets for action, that’s sort of rule number one in the assurance function. What is it we’re trying to do to assure health? We can provide direct services. Again, some of us do that more or less. We can collaborate with others. We can go the regulatory route, that’s not our usual MO, we usually don’t do that, but sometimes that’s the only thing we can do.

What are the--the folks from Puerto Rico had legislation passed that every physician, tell me if I’m wrong, I think, every physician in the state had to be trained on breastfeeding; every physician. Not every obstetrician, or pediatrician, neurologist, cardiac surgeons, they all have to be trained on breastfeeding. Well, you know, I think they’re now rethinking that but, you know, they had leadership that cared about breastfeeding, oh, boy, and they went the regulatory route, you are mandated to be trained in breastfeeding. Again, that’s not our normal route but sometimes the stars align and you can do it that way. Educating, advocating, gathering data, these are all of ways that we can think about assuring what we do.

So, again, program planning is all of these things. It’s the assessment of the need. It’s the priorities. It’s the solutions. It’s your plan of action: how you’re going to allocate your resources, how you’re going to monitor and evaluate and track your performance. You can’t just do the needs assessment and shelve it. You know that you wouldn’t be here if you didn’t know that. We’re talking about change here.

Now, when we talk about plans, we’ve got to be very clear. Plans should be directive; they should be very clear. They should let everybody know what it is you are trying to do: for whom, by, when, and how. We’ll talk a little bit more about this later, and we want to monitor what we do, who’s responsible? You can’t just gather a group of people in a room and say, “Alright, we’re going to launch the methamphetamine initiative,” and then leave. I mean, who’s going to do that? What are they going to do? And what schedule are we going to review what’s happening? And how’s the progress of the process going to be measured and communicated? And you know, we’re all guilty of this, we launch something then we go away as leaders because we get a hundred things going on. But if we’re committed to this plan and the implementation, then we got to stick to it. We got to know who’s doing it, we got to make sure things are happening, we have to monitor what we’re doing and communicate our success.

Now, hopefully, the data that led you to identify the need in the first place provides a baseline or a place to start so then you can set some targets. You know, if my infant mortality rates is here and I want it to be here, then I can set that target. Performance measures are one way we document our success to the extent that you know--how many of you have performance measures that link to your priorities? So, a lot of you do. And again, that’s been an evolution too. You know, early on there’ll be sort of priorities here and performance measures here, and they didn’t necessarily connect. And that’s not--that’s okay. You just have to think about how you’re using them and the extent to which they monitor. Okay.

Now again, when we talk about change and new plans, and new priorities, ultimately, you’re usually talking about money and how you allocate resources and, again, the data that you used to identify the need in the first place can also help you then in the resource allocation phase. And I like--I do this with my students all time, they say, “Alright, you’re at the state level and you want to get money out to the counties, how should we do that?” And they always say, it never fails, “Oh, we’ll just give every county their share, their equal share.” And they all nod and then someone gets that look on their face and says, “Well, that might not work because some counties have more people than others.” And there’s one, “Oh, well, you should allocate it on per capita basis.” And everyone goes, “Yeah, yeah, yeah.” And then someone gets the look on their face and says, “Well, wait a minute. Maybe counties have different needs.” Okay. Well, now, if you’re going to allocate it on the basis of need, you better have the data that documents the need because what happens when you start allocating on need? I get more, I get less, he doesn’t deserve that, I do. And in fact, some of you are even looking at allocating on capacity or on performance. You know, this whole pay for performance movement. Well, that’s the challenge for you because you got to meet needs, but you also want to make sure that you’re not, you know, penalizing someone who doesn’t have the capacity to meet the need, whether it’s training or personnel, you know, all those things. But on the other hand, you’d love to reward people who do well, you know, that would be a good thing to do.

So, you know, as we get into more sophisticated resource allocation systems, you better have the data to back it up and ideally, people have been involved all along. They’ve been following this data just like you have. And they can see where these trends are going. And so, they might grumble but at least they can say, “Well, alright. I don’t like it but I understand why they did it this way.” Right? Okay. Everyday, right now, as we sit here, new babies are being born, we don’t know what they’re going to face. The future of MCH is your responsibility. You got to do the best job you can do: thinking strategically, opportunistically addressing those needs, changing what you do. Maybe you have to let some things go in order to take on some new opportunities. How do we make life better? That’s what we’re about here. And remember, no one else does this. No one else has this responsibility. You’re the only ones. You have the broad responsibility. You have, perhaps, the moral authority. It doesn’t make your job any easier, we can’t walk into your neighbor’s agency and say, “I’m here with this staff of moral authority and you’re going to do what I say,” but it’s hopefully, what kind of drives us collectively, to do the best that we can do.

And with that, I’m going to stop. Any questions or comments before I turn it over to Joan? Great. Joan’s going to talk about myths and realities.