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 weÕve had by far so, weÕre going have to do a little bit
of adjusting on the time because we do a lot of small group work because thatÕs
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, weÕll 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 whoÕs here and what states and what
programs and again, itÕs 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, letÕs start over here in the corner.
GRETCHEN: Gretchen (Inaudible), IÕm from Iowa.
(Inaudible).
MELISSA ELLIS: IÕm Melissa Ellis (Inaudible)
DONNA PETERSEN: Can you hear her?
MELISSA
ELLIS: IÕm Melissa Ellis, IÕm from Iowa and IÕm a program trainer for Maternal
and Child Health.
DONNA PETERSEN: Great.
BERTH
COLE: IÕm Berth Cole and IÕm with Special Needs Program with Iowa Corp
(Inaudible).
ROBERTA
LACARTHY: Roberta Lacarthy from the Texas Department State Health Services and
The ChildrenÕs Special Health Care Needs Program and Assisting Development.
MICHELLE
BRADLEY: IÕm Michelle Bradley from (Inaudible), New York (inaudible) Health
Department.
MICHAEL
GRATSKY: Good morning IÕm Michael Gratsky and IÕm 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, IÕm from Austin, Texas and IÕm working with the type of
bioresearch team (Inaudible).
JOHN
GOURLEY: IÕm John Gourley from Minnesota and I specialized in (inaudible)
MARCY
BRACKIS: IÕm Marcy Brackis from Glendale and IÕm supervising (inaudible)
MELISSA
DAVIS: Melissa Davis from Connecticut. Connecticut (inaudible) Director and
section chief (inaudible)
DONNA PETERSEN: Welcome.
ED
CRUE: Good morning. IÕm Ed Crue, IÕm from Indiana. IÕm the director for
Maternal and ChildrenÕs Special Health Care.
BOB: IÕm Bob (inaudible) and IÕm 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: IÕm Pauly York, IÕm an Administrator of Office of Family Health
(inaudible) while completing services and regulating the crisis.
CANDICE: Good morning. IÕm Candice from Internal
(inaudible)
DONNA PETERSEN: Great. Go back in.
UNKNOWN SPEAKER: (Inaudible).
DONNA PETERSEN: Okay, way in the back.
RWANDA
SANDERS: IÕm Rwanda Sanders. IÕm 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: IÕm Mylene Myer, IÕm the director of Children and Family Section. at the
Bureau for Children and Family (inaudible)
BEVERLY
ENGLISH: Good morning. Beverly English, IÕm from Illinois. IÕm Chief of Maternal (Inaudible).
GARY
PARKINSON: Good morning IÕm Gary Parkinson, IÕm the chief of the Bureau of
Special Healthcare within the Missouri Department of Health Services.
SUSAN
BERRY: IÕm Susan Berry and IÕm the Medical (inaudible) for Corporate Special
Healthcare (inaudible)
GERALDINE
MCGARTH: IÕm Geraldine Garth, Louisiana Child Healthcare (Inaudible).
CLINT
MILLER: Hi IÕm Clint Miller, IÕm 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 IÕm Nancy Helleger, from Arkansas, (Inaudible) with Children With
Special Healthcare needs.
DICK NUGEW: IÕm 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: IÕm Dick Lawrence, Oklahoma State Health Department and Recreational
Assessment.
SUSSY
LYNCH: Sussy Lynch, chief of Maternal Child Health Services (inaudible)
LIZ ROCK: Hi IÕm Liz Rock and I coordinate with
(Inaudible).
JESSY
SHARON: Good morning my name is Jessy Sharon and IÕm also from Ohio, and IÕm
the acting chief of the Bureau of Child Healthcare Services (inaudible).
JERI
CLARKE: IÕm Jeri Clarke, IÕm from Illinois Children Special Healthcare Program.
SUSAN
NUETER: Hi, IÕm Susan Nueter, from Divisional Public Healthcare (inaudible)
LINDA
HALE: IÕm Linda Hale. IÕm a (inaudible).
DONNA
PETERSEN: Wonderful. What a handsome group. Delighted that youÕre 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, weÕre delighted to welcome you. Folks from New Jersey, were down
in region four, and that was actually nice. You know, itÕs 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 weÕve said already, we will be
presenting some information to you but weÕre 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, youÕre 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 youÕve 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, weÕre 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 thatÕs 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 youÕre 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 weÕve done collaborative assessment
and a little bit of priorities setting, how that we then move that agenda
forward? And thatÕs part of the challenge that weÕre going to talk about today.
So,
weÕre 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.
WeÕre going to talk about some of the myths and realities of about priority
setting and program planning. Then weÕll put you in some small groups to focus
on some of the challenges that you faced. Then weÕll 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 weÕll do our best to keep
it lively for you. Then weÕll comeback tomorrow and focus the morning on the
process of managing change, and I think youÕll enjoy that. ThatÕs a fun
session. Okay? Sound good?
All
right, youÕve 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 itÕs important to sort of remind us
where we sit, though itÕs interesting in this region and IÕm familiar with the
number of the states here, youÕve gone through some re-organizations, youÕre
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 IÕve had the opportunity lately to do a lot of
speaking to community groups with lay audiences about public health. And itÕs
interesting, because people donÕt--you know, whatÕs public health? And the word
public kind of trips us up sometimes because public has a connotation that
isnÕt 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, ÒWould you prefer
to be healthy or not healthy?Ó They look at you like youÕre crazy, ÒOf course I
want to be healthy. We all want to be healthy.Ó 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. ThatÕs 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, itÕs in everybodyÕs national interests, to assure the health of the
children because they are our future. Now we say that, and you say, ÒOh well,
you donÕt know just like in my state.Ó ItÕs sometimes hard to translate that
message to policy makers and elected officials, but we know in our hearts itÕs
true, and most people when pressed will say, ÒYes, I would prefer my children
be healthy and grow up to be healthy adults.Ó 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 thatÕs
a hard sell. ItÕs hard to get people excited about the things that didnÕt
happen. Though we certainly in our colleagues from Louisiana, and they didnÕt
know I was listening to them on the shuttle from the airport yesterday, talking
about you know, you have to be careful, you know, IÕm 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, itÕs 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. ItÕs part of our statutory mandate. ItÕs
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 youÕve 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 canÕt do it all on our
own. We simply donÕt have the capacity to do all the things that we would wish
to do. So, weÕve 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. WeÕre the only ones that have this overarching responsibility. All
those other programs that we work with that provide pieces of that system donÕt
have this broad responsibility, this idea that you are responsible for assuring
the health of all the women, children, family, childrenÕs with special needs,
youth in your state is a tremendous responsibility, and you Ôre 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. ThatÕs how we kind of frame what weÕre
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
werenÕt around, then youÕre too young. Back in the third grade, we all read the
Institute of Medicine -- wouldnÕt 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, ÒWe donÕt have a public health system in this country. ItÕs
a mess. We donÕt agree on what it is. We donÕt agree on what itÕs supposed to
do. We donÕt agree on how to be organized. We have state, local, sometimes, no
local, you know, --. ItÕs a mess,Ó and so, they articulated what is public
health, and the way I defined it for you is directly from that report, ÒWhat we
do collectively to create conditions in which people can be healthy,Ó 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 weÕre going to talk about these a little
bit today, but it was a way of framing what public health is and what itÕs not.
It makes it clear that weÕre about the population, I think. WeÕre out there
assessing those conditions that affect peopleÕs health. We are then working to
develop policies and programs and garner the resources to address those things
that affect peopleÕs health, either shoring up those that are positive or
working to reduce those that arenÕt and then assuring that those things are in
place. So, itÕs a different kind of focus. ItÕs different from the Medicaid
program. ItÕs different from clinical healthcare. ItÕs 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 donÕt
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 wasnÕt
terribly new. This is kind of what weÕve 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 weÕve been doing for years, and you can
kind of sit in the back and sigh, or you can say, ÒWell, IÕll take the lead on
that because I know what IÕm doing,Ó and there are a number of states that took
that opportunity to do that. Well, a lot of folks got together and said, ÒWell,
that was a nice report, and we like those core functions, but theyÕre not
explicit enough, and we need to do a better job of explaining what it is that
public health does.Ó 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 werenÕt 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
thereÕs a copy in the back of your notebook in case youÕve misplaced your
provisional copy, because theyÕre nice. TheyÕre 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. ThatÕs where our orientation is.
We need to provide the leadership thatÕs 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 weÕll 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, weÕre 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, ÒWe donÕt do research. ThatÕs
what you and academia do.Ó But the fact of the matter is, every time you try
something new and weÕre going to talk about that today. You did some needs
assessments. You set some priorities. YouÕre going to be trying something new.
YouÕre engaging in research, if you will. You didnÕt write a grant to NIH. You
didnÕt derive a hypothesis but you are going to show us that this works or
doesnÕt work. And the extent to which you can share that knowledge with the rest
of us helps advance all of us. So, itÕs like 59 natural experiments. You know,
youÕre all out there responding to your local needs. YouÕre all trying new
things. WeÕve got to do a better job of sharing that and learning from each
other so that we donÕt have to make the same mistakes or reinvent wheels, or
those things. And IÕm 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. WeÕve got broad public health responsibility but then
weÕve got sort of intensive responsibility for those things that we canÕt 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 weÕre 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, youÕre responsible for everything that goes on whether itÕs across the
public health sector or all those other agencies and good golly, you know, IÕve
only got three people in this office and weÕre trying to do the lead program
and the prenatal program and transition kids with special needs and IÕm
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 weÕve got this huge
responsibility. We have very few resources and theyÕre dwindling for most of
us. I donÕt 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 canÕt retain them. We canÕt 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 weÕve 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,
youÕve 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 doesnÕt
matter. The point is just to illustrate a couple things. One is that this is an
ongoing process. We donÕt have the luxury of stopping everything. ItÕs ÒOkay,
everybody stop. WeÕre going to plan and when weÕre done, then weÕll implement
the plan and then you can all start again.Ó Things are happening while youÕre
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. YouÕre planning all the time. You just did a five-year needs
assessment but then that youÕre not done assessing needs. YouÕre assessing
needs all the time. YouÕre always taking in information and youÕre planning and
youÕre coming up with goals and objectives and youÕre implementing and youÕre
adjusting and youÕre planning for evaluation and itÕs an ongoing process. Okay?
Just a simple illustration of what youÕve 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, itÕs 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, IÕve 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, weÕre in the position of responding to an external mandate that
we didnÕt generate, we wouldnÕt have suggested, but youÕve got it now. Right?
The legislature comes up with something. The governorÕs wife goes somewhere and
comes back with the next great idea. Right? Please donÕt go anywhere. DonÕt go
to that meeting. And itÕs hard just--you canÕt 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 canÕt 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 everyoneÕs priorities. And I hope weÕre going to get everyoneÕs
homework, because itÕs 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, ÒI got bike helmets on the list.Ó 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, ÒWeÕre going to reduce injuries.Ó 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. ItÕs an ongoing
cycle. You assess problems, needs. Perhaps you looked at assets and strengths.
You thought about solutions. Now youÕre going to have to implement those
solutions. YouÕre going to have to allocate resources in order to make that
happen. We want you to evaluate what youÕve done. YouÕve got to monitor your
performance because youÕve 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 doesnÕt change. ItÕs 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. ItÕs an ongoing engaged process. ItÕs complicated.
But again, we know this because weÕve been doing this since 1912 when the
ChildrenÕs 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 itÕs what the language said.
This
responsibility thatÕs in Title Five, to assure the health of all mothers and
children, requires that you do this. It doesnÕt, you know, regardless of
whether itÕs a core public health function or in the law. You have to do this
anyway. You canÕt perform that function. You canÕt achieve that goal if you
donÕt know whatÕs going on that affects the health of women and children and
families in your state. So youÕre doing this all the time. YouÕre 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 youÕre 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. ItÕs about
change. And those of you that were with us two years ago, weÕve spent a lot of
time talking about, if you donÕt--if youÕre not willing to change, if youÕre
not willing to consider changing, then you really shouldnÕt 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 youÕre going to have to change something. It is
highly unlikely, that youÕre going to do a needs assessment and find that you
have no needs or that theyÕre all being met. I mean, it would be marvelous if
that were true but thatÕs not whatÕs 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, ÒIÕm going to be assessing needs, IÕm going to be making decisions, IÕm
going to be setting priorities,Ó means youÕre going to have to change. Things
are going to change. And thatÕs okay because thatÕs what strategic planning is
all about. And when you responded on your technical assistance request forms
and said, whatever you said, you know, ÒWe need some help, because itÕs hard.Ó
Change is really hard. People donÕt like change.
YouÕre
going to be engaged in a strategic planning. YouÕre going to be setting some
directions. YouÕre 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. ThatÕs what youÕre
trying to do here. YouÕre trying to improve the lives of the children and
families in your state.
Ongoing
processes, the Five-Year Needs Assessment--again, itÕs a point in time, and
itÕs kind of a nice point in time because it forces you to sort of, stop and at
that point in time at least say, ÒAll right, letÕs kind of re-look at where we
are. LetÕs re-engage folks. LetÕs look at our data systems. LetÕs figure out if
weÕve got to change things.Ó 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 donÕt tell you because youÕre not collecting data
on that because you didnÕt know it was a problem. It only just emerged or youÕre
not allowed to collect data on that politically or whatever the reason is. So,
maybe part of the strategy is, ÒI need to know more.Ó Maybe the strategy for
child obesity prevention is, ÒI need to know more because I donÕt necessarily
know how to act.Ó I can see that itÕs a problem. In fact, I donÕt the data they
show me. ItÕs, I just have to go to the mall and I can see itÕs a problem. But
what do I do about it? ThatÕs not so easy. So, maybe I need to gather more
data. Maybe I need to follow ArkansasÕ 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 itÕs funny how youÕve been
seeing it all along but now youÕre acutely aware of it, you know. Do you watch
what eat people now when youÕre out? Do you watch what they put in their
grocery carts? I mean itÕs terrible. I canÕt go to the grocery store. IÕm
looking at everybodyÕs carts. And IÕm looking at what the kids are eating and,
you know, you look at people and think, ÒGod, what, you know, do you not know
any better?Ó Well, maybe they donÕt. Maybe no one ever explained it or maybe
theyÕre not making the connection, or maybe that itÕs 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 donÕt remember the guyÕs 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, ÒDo we really have to keep funding MCH? ArenÕt you
people done?Ó And IÕm like, ÒNo, because right down the street here at the
local hospital, thereÕs babies being born and we donÕt know what challenges
theyÕre going to face.Ó We donÕt know what the worldÕs going to be like. WeÕre
never done. WeÕre never done. But you know, but in his mind, theyÕd 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 thatÕs been placed in us. WeÕre public servants. We rely on public
dollars to do our work. And we know weÕve 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, weÕve seen it
evolve tremendously from 1990, I think, when the first round after Õ89. I donÕt
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, ÒOh well, gee, I didnÕt know we had those needs and
now IÕm going to change my whole program.Ó I mean, it was a really daunting
task. WeÕve moved a tremendous distance from then. Okay..
And
again, there were key elements that you utilized in that needs assessment
process that youÕre going to want to continue, because these are ongoing
processes and you donÕt 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. WeÕre going to talk about why itÕs important to
keep that up.
You
utilized the scientific knowledge-base to the extent that itÕs out there for
you to utilize but you used it. You recognize the politics of MCH. Needs
reflect the values of your constituency. TheyÕre not a number. TheyÕre 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 youÕre doing, build awareness of what youÕre doing, build acceptance for
what youÕre doing, advocate for what youÕre 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. TheyÕre concerned about how weÕre changing thatÕs 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
youÕre doing. Let them explain that what youÕre doing is for all of these
reasons. Let them go to the legislature, either with you or when you canÕt and
weÕll talk about that a little bit too. ThereÕs times when you canÕt go. So,
whoÕs 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, itÕs like, sometimes, these can become unwieldy but itÕs 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 youÕre doing. You know the past, and itÕs been now at
least 10, 15 years, where the perception portrayed by the media, you know, itÕs
like all of the government is bad. You know, big government is bad. Public
sector is bad. You know, and youÕre part of this. ThatÕs what I was saying
before when people think public, they think bad, things I donÕt want to ever
have to utilize, you know. I donÕt ever want to have to use public
transportation. I donÕt ever want to have to use a public bathroom, for crying
out loud. You know, and your part of the government; the governmentÕs bad. You
know, itÕs 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, ÒHey, this is not
government. This is health. This is in your best interest because you all want
to be healthy. ItÕs what we do to ensure our future.Ó 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 youÕre 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 youÕre 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?
ItÕs
wonderful to see the number of MCH epidemiologists in these states. And again,
thatÕs a huge change from where we were 15 years ago. You know, these people
didnÕt exist, and you didnÕt have that kind of capacity, now you do. So, you
want to maintain it, you want to make sure theyÕve got what they need to do
their job. Do you have what you need to monitor what youÕre 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 publicÕs mind? And part of that is continuing to put out
the data. WeÕll 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 donÕt, 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? ÒOh, heck IÕll just roll those in
my trunk and IÕll get to it next week or maybe I wonÕtÓ. Okay.
You
want to be mindful of your data: whereÕs it coming from, whereÕs it going,
howÕs it getting utilized? You set priorities. Maybe you need to revisit
them. You know, you set them but
theyÕre not set in stone. Cassie will tell you, ÒYou can modify them as you go
because youÕre going to keep learning.Ó As you plan and implement and engage in
this change process, youÕre 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 youÕre 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 youÕre
engaged stakeholders. Does the community perceive that this is a problem? Because if they donÕt, theyÕre not
going to pay any attention to what youÕre 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
arenÕt there, youÕre wasting your time. People have to agree itÕs a problem and
accept the solution that you proposed. And thatÕs why itÕs 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.
ThereÕs no escape. We know there are political issues related to a lot of what
we do. When you discover something through your assessment, youÕre kind of
thinking about this, you will often run into things that arenÕt within your
scope of responsibility. People will tell you about things that affect their
health that they want somebody to do something about. ItÕs not your
responsibility. But now that you know about it, because youÕve 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 doesnÕt mean you suddenly have to become the housing
agency. But it means you need to be over with the housing agency saying, ÒLook,
you know, IÕm trying to promote peopleÕs health. TheyÕre telling me that they
got lousy housing and–or they canÕt get any at all because itÕs not
affordable or whatever it is. Can I work with you on this?Ó And lastly, what
are the resources that you have to do this? You can identify a serious problem,
if you donÕt know what to do about it. ThereÕs very little point in making it a
top priority because what will you do about it? Though weÕre going to talk in a
minute about other ways that you can address those kind of priorities. Like
right now, IÕm going to talk about it.
Those
of you that were here a couple years ago may or may not remember this; weÕve
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 youÕve got these groups and theyÕre
recommending things to you, and theyÕre not recommending things to you that
youÕre mandated to do? That was sort of the first issue. ItÕs like well, you
know, theyÕre 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 ÒB-list.Ó You know, there are things that you know youÕre going to
do that you may or may not want to put on your 10 priority lists but you know
theyÕre 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 youÕre 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–ChildrenÕs Defense Fund, you know, theyÕve all got their issues and
thatÕs the kind of typical stuff and thatÕs what youÕre debating and then, you
know, will should it be more prenatal care, should it be postpartum depression,
Okay, those kinds of things. But then, youÕve got these things that come up,
like childhood obesity is a good example. Well, everyoneÕs talking about it but
we donÕt 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 theyÕre on another list that you keep somewhere, either in your head
or in your own agency where--all right, I canÕt ignore methamphetamine because
everybody brought it up. ItÕs not my issue. We donÕt know what in the world
weÕre going to do about it, but I canÕt just blow it off because it came up
every time I went out into rural Arkansas or rural Missouri and it came up. So,
IÕm going to put it somewhere else. But IÕm not going to lose it because people
are very concerned. Two years ago, IÕve only got 10 priorities? IÕve got more
than 10 programs. I got 15 programs. How do I only have 10 priorities? Well,
you know, thereÕs other ways to utilize that information when youÕre thinking about
planning. Okay?
Now, hopefully, when you came up with your
priorities, you thought about solutions. Because again, itÕs 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
donÕt just say, ÒOh, yeah, weÕre going to take on the meth problem.Ó But put
that at the top of the list. Well, because now youÕre sitting here, itÕs
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 whatÕs 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, weÕre 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 weÕve
been doing. Okay.
So, we can go back to those other functions. We can think
about policy solutions, broader assurance solutions, youÕve got the
definitions. You know what they are. And again, as I said, you will learn
things, through a comprehensive needs assessment that arenÕt 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 thatÕs
whatÕs affecting your population, or if itÕs housing, you know, you can provide
prenatal care till the cows come home, but if they go home to infested
dangerous toxic environment, then youÕve 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. TheyÕre worried about education. TheyÕre worried
about environmental issues. TheyÕre 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, youÕve 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. IÕm sorry, I keep hitting
that--you know, youÕve 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 itÕs 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, IÕve 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,
thatÕs obvious because itÕs not your issue. ItÕs somebody elseÕs issue, but how
do you convince them to do that or maybe itÕs a truly shared issue, and maybe
you have to give up. You know, I donÕt 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 thatÕs 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. ThatÕs 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 itÕs
not you, it has to be the next person. Assurance, you know the definition
there. We know we have to set targets for action, thatÕs sort of rule number
one in the assurance function. What is it weÕre 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, thatÕs not our usual
MO, we usually donÕt do that, but sometimes thatÕs the only thing we can do.
What
are the--the folks from Puerto Rico had legislation passed that every
physician, tell me if IÕm 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 theyÕre 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,
thatÕs 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. ItÕs the assessment of the
need. ItÕs the priorities. ItÕs the solutions. ItÕs your plan of action: how
youÕre going to allocate your resources, how youÕre going to monitor and
evaluate and track your performance. You canÕt just do the needs assessment and
shelve it. You know that you wouldnÕt be here if you didnÕt know that. WeÕre
talking about change here.
Now,
when we talk about plans, weÕve 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. WeÕll talk a little bit more
about this later, and we want to monitor what we do, whoÕs responsible? You
canÕt just gather a group of people in a room and say, ÒAlright, weÕre going to
launch the methamphetamine initiative,Ó and then leave. I mean, whoÕs going to
do that? What are they going to do? And what schedule are we going to review
whatÕs happening? And howÕs the progress of the process going to be measured
and communicated? And you know, weÕre all guilty of this, we launch something
then we go away as leaders because we get a hundred things going on. But if
weÕre committed to this plan and the implementation, then we got to stick to
it. We got to know whoÕs doing it, we got to make sure things are happening, we
have to monitor what weÕre 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, thatÕs been an evolution too.
You know, early on thereÕll be sort of priorities here and performance measures
here, and they didnÕt necessarily connect. And thatÕs not--thatÕs okay. You
just have to think about how youÕre using them and the extent to which they
monitor. Okay.
Now
again, when we talk about change and new plans, and new priorities, ultimately,
youÕre 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, ÒAlright, youÕre at the state level and you want
to get money out to the counties, how should we do that?Ó And they always say,
it never fails, ÒOh, weÕll just give every county their share, their equal
share.Ó And they all nod and then someone gets that look on their face and
says, ÒWell, that might not work because some counties have more people than
others.Ó And thereÕs one, ÒOh, well, you should allocate it on per capita basis.Ó
And everyone goes, ÒYeah, yeah, yeah.Ó And then someone gets the look on their
face and says, ÒWell, wait a minute. Maybe counties have different needs.Ó
Okay. Well, now, if youÕre 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 doesnÕt 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, thatÕs
the challenge for you because you got to meet needs, but you also want to make
sure that youÕre not, you know, penalizing someone who doesnÕt have the
capacity to meet the need, whether itÕs training or personnel, you know, all
those things. But on the other hand, youÕd 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. TheyÕve 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, ÒWell, alright. I donÕt like it but I understand why they did it this
way.Ó Right? Okay. Everyday, right now, as we sit here, new babies are being
born, we donÕt know what theyÕre 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? ThatÕs what weÕre about here. And remember, no one else does
this. No one else has this responsibility. YouÕre the only ones. You have the
broad responsibility. You have, perhaps, the moral authority. It doesnÕt make
your job any easier, we canÕt walk into your neighborÕs agency and say, ÒIÕm
here with this staff of moral authority and youÕre going to do what I say,Ó but
itÕs hopefully, what kind of drives us collectively, to do the best that we can
do.
And
with that, IÕm going to stop. Any questions or comments before I turn it over
to Joan? Great. JoanÕs going to talk about myths and realities.