Facilitating the NPHPS Local Instrument

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Facilitating the NPHPSLocal Instrument

• Laurie Call, Illinois Public Health Institute
• Teresa Daub, CDC

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Learning Objectives

• Following this session, you will be able to
• Describe the framework and concepts that underpin
  the Local NPHPS tool
• Discuss the similarities and differences between
  Versions 2 and the re-engineered Local NPHPS
  tool
• Describe the recommended NPHPS facilitation
  process
• Apply at least two recommended NPHPS facilitation
  strategies and
• Utilize related resources to plan and implement
  the Local NPHPS assessment.

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Overview of the National Public Health
Performance Standards (NPHPS)
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NPHPS Vision

• A partnership effort
• to improve the
• quality of
• public health practice
• and
• performance of
• public health systems

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NPHPS

• Three Assessment Instruments
• State public health system
• Local public health system
• Local governance

• Partners
• CDC
• APHA
• ASTHO

• NACCHO
• NALBOH
• NNPHI
• PHF

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Framework of the NPHPS
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Four Concepts Applied in NPHPS
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Public Health System
Fire
Mental Health
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Stimulate Quality Improvement

• Standards should result in identification of
  areas for improvement
• Link results to an improvement process

MAPP (Mobilizing for Action through Planning and
Partnerships)
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NPHPS Local Materials
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NPHPS Version 2.0 (2007) and Re-Engineered (2012)

• Both versions
• Are grounded in the 10 Essential Public Health
  Services
• Use a semi-qualitative rating scale
• Can contribute to health improvement planning as
  well as strategic planning activities
• Re-engineered
• Has fewer scored questions
• Incorporates plain language principles
• More discussion-focused (relies more heavily on
  facilitation)
• Has increased quality improvement focus

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Version 2 Instrument Format
Essential Service
Model Standard
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Version 2 Instrument Format
Measures or Questions
Discussion Toolbox
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Re-engineered NPHPS Fall 2012

• Streamlined the assessment tools
• Enhanced systems building aspects of the
  assessment process
• Increased quality and performance improvement
  activities
• Strengthened linkages with accreditation

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• Essential Service
• Description
• Includes list of potential system partners for
  each Essential Service

Field Test DRAFT
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• Model Standard
• Description
• Uses plain language

Field Test DRAFT
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• Model Standard
• Discussion Questions and Performance Measures
• More discussion
• Fewer scored questions

Field Test DRAFT
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• Essential Service Summary Notes Page
• Framework for identifying
• Strengths
• Weaknesses
• Opportunities
• Priorities

Field Test DRAFT
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Facilitation Process
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General Principles of Facilitation

• Facilitators
• Guide participants through the process
• Focus on HOW people participate, not just on WHAT
  is stated or completed and
• Maintain neutrality and do not take sides.
• Adapted from the Community Tool Box
  (http//ctb.ku.edu/)

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NPHPS facilitators help participants. . .

• Complete the NPHPS assessment with documented
  discussion and scores related to each performance
  measure
• Enhance understanding of the local public health
  system
• Build relationships within the local public
  health system and
• Foster an interest and awareness in performance
  improvement.

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Facilitation Process

• Step I Preparation/ Determine approach to ES
  Conversation
• Step 1 is completed prior to the NPHPS
  event(s).
• Step 2 Welcome and Introduction
• Step 3 Process Overview
• Step 4 Review Essential Service and Model
  Standards
• Step 5 Facilitate Responses to Discussion
  Questions
• Step 6 Preliminary Vote/Scoring Performance
  Measures
• Step 7 Consensus Building
• Step 8 Essential Service Summary Discussion

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Step 1 Facilitator Preparation

• Determine approach to beginning the conversation
  regarding what is going on related to the ES in
  the specific area (Step 4).
• Refer to activity
• Review essential service chapters.
• Identify and clarify challenging terminology.
• Consider if any discussion questions or
  performance measures that may need clarity for
  your local group.
• Have a clear understanding of the voting and
  consensus processes. Identify useful questions
  to solicit views from participants when they are
  diametrically opposed.
• Review the facilitation process.
• Review the facilitation tips and suggested
  questions.

Facilitator Prep Road Map
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Step 2 Welcome and Introductions

• Introduce facilitator, recorder and the roles of
  each
• Ask participants to introduce themselves
• Name
• Organization
• How their organization/agency contributes to
  local public health system (brief)

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Step 3 Process Overview

• Review purpose, goal and time-frame for the group
  work
• Review participant materials
• Review the ground rules, solicit any additional
  ground rules and get participant agreement on the
  ground rules
• Review the process outline (poster) to explain
  the steps in the group work
• Highlight posters and how they will be used

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Facilitated Group Session Posters

• Ground Rules
• Process Outline
• Discussion Areas
• Criteria to Consider When Scoring
• Scoring Poster
• System Egg Chart
• Summary and Wrap-up Guidance

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Ground Rules

• Stay Present (phones on silent/vibrate, limit
  side conversations)
• Speak One at a Time
• Be Open to New Ideas
• Step Up/ Step Back
• Avoid Repeating Previous Remarks
• Allow Facilitator to Move Conversation Along
• Use Voting Cards to Vote and Discussion Card to
  Request Additional Discussion

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Process Outline

• Introductions
• Review of Ground Rules
• Process and Material Overview
• Read Essential Service and Activities
• Report on Essential Service Activities in the
  Community
• Participant Reflection and Input (Discussion)
• Repeat for Each Model Standard
• Reading and Discussion of Model Standard (10-15
  min)
• Facilitation of Discussion Questions
• Scoring of Performance Measures
• Further Discussion as Needed/ Re-vote as
  Necessary
• Agency Contribution Questions (optional)
• Note Take Away Messages/ Record Discussion Points
• Consensus on Final Score
• Summarize Overall Group Discussion on Essential
  Service for Report-Out
• Strengths, Weaknesses, Opportunities for
  Immediate Improvement/ Partnerships and
  Priorities

Facilitation Road Map
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Discussion Areas

• What is the collective picture of how we are
  doing across the County related to this Essential
  Service?
• Keep focus on model standard.
• Stay focused on system as a whole.
• Purpose is to get honest and accurate perception
  of the strengths and weaknesses of the system for
  quality improvement.
• Share concrete examples.
• Share strengths.
• Share weaknesses.
• Suggest recommendations for immediate
  improvement.
• Suggest priorities.

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Purpose of Discussion

• NOT to criticize a particular agency or
  organization
• One of the most beneficial components
• Informing the Collective Vote
• How well we think the system is doing
• Why we feel the way we do
• Specific examples of what we are doing

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When voting, think about the focus of the
question in terms of

• Awareness
• If one system partner indicates that his or her
  organization provides a particular public health
  service, do other system partners know about it?
  
• For example, if the local health department leads
  the community health assessment (CHA) process,
  are most system partners aware of the CHA and
  know how to access it?
• Does the LPHS engage in activities to increase
  awareness of particular services or activities?
• Involvement
• Are public health services provided within the
  LPHS in a coordinated and efficient manner?
• Is the service provided in one sector of the LPHS
  and not in others where appropriate? (e.g.
  provided in hospitals, but not by governmental
  public health agencies)
• Should the service be provided by other sectors,
  that is, are there service gaps?
• Are several sectors providing the same service
  creating redundancies in the system?
• Frequency
• Is the activity or service completed routinely or
  on an ad hoc basis?
• Is the activity or service completed based on
  best practice implementation schedule standards?

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When voting, think about the focus of the
question in terms of

• Quality and Comprehensiveness
• Is the service or activity provided based on
  evidence-based research, theory-based, with clear
  rationale or according to practice standards?
• Are measurable process and outcome data available
  related to the public health service or activity
  and its impact?
• Is the service/ activity too new or at an early
  implementation stage where quality improvements
  are still needed?
• Is the service being provided in a comprehensive
  manner?
• Are there adequate resources to complete the
  activities?
• Utility
• Is the activity in the question
  disseminated/dispersed across the locality
  geographically, or does it exist in only one area
  of the community?
• Is the activity dispersed among programs or only
  addressed in one area of public health?
• For example, health promotion activities might
  occur in maternal and child health programs, but
  not in areas of chronic disease, infectious
  disease, or injury prevention.
• Are the results and information derived from
  public health assessment, research, evaluation
  and other activities used to improve public
  health?

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Public Health System
Fire
Mental Health
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Summary and Wrap-up Guidance Questions

• Summarize the discussion after each Essential
  Service by listing the following

• Strengths
• Weaknesses
• Opportunities for Immediate Improvements or
  partnerships
• Longer term improvements needed

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Step 4 Review Essential Service and Model
Standards

• Use the process and scripting in the facilitator
  guide.
• State the Essential Service and the core
  question(s) that the ES is addressing.
• Read the activities that comprise the ES.
• Review the potential LPHS partners typically
  engaged in the work and ask participants to
  identify which are present and which are not.
• Review the first model standard. Address any
  clarification questions.
• Ask participants to describe how the LPHS
  contribute to the model standard. Round robin
  works well if time for each participant is
  limited.
• Ask probing questions as necessary to ensure that
  all parts of the MS are discussed.

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Participant Guide Essential Service Description
Field Test DRAFT
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Participant Guide Model Standard Description
Field Test DRAFT
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Exercise
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Step 5 Facilitate Responses to Discussion
Questions

• Use the discussion questions to more fully
  explore the MS activities within the LPHS.
• The questions lead to specific detail that will
  be necessary to understand for scoring the level
  of activity for the LPHS around each performance
  measure.
• Be sure to ask all questions.
• Recorders will document all responses.

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Participant Guide Model Standard Discussion
Questions and Performance Measures
Field Test DRAFT
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Step 6 Preliminary Vote

• Based on the discussion and sharing of examples,
  ask participants to vote on the level at which
  the LPHS is performing for the each of the
  two-five performance measures.
• Encourage them to think about the entire system
  and not specific organizations.
• Encourage participants to assign the score that
  best describes the current level of activity
  within the system shared during the discussion
  period.
• Performance measures are all defined as optimal
  standards. Therefore, in order for a measure to
  be scored optimal, the LPHS would have provided
  comprehensive examples of high quality work
  across all public health areas and the
  jurisdiction under any one standard to look
  similar to, and function consistently with, the
  model standard. 

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Step 7Consensus Building

• Work towards reasonable consensus.
• Not Majority, Unanimity etc.
• Goal is not to have extreme outliers
• In the event there are diametrically opposed
  answers or a participant has a strong need to
  discuss an issue, stop and determine why there
  are contradictory views.
• Goal is to have a score that is a good
  representation of the collective voice
• Is this a score you can live with?
• You might not agree 100, but good representation
  of collective

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Voting Considerations

• Awareness
• Even if the work is occurring, do people know
  about it?
• Involvement
• Are public health services provided within the
  LPHS in a coordinated and efficient manner?
• Frequency
• Is the service or activity completed routinely
  and according to best practice time-line
  standard?
• Quality and Comprehensiveness
• Is the service or activity provided based on
  evidence-based research? Are measurable process
  and outcome data available?
• Is the service being provided in a comprehensive
  manner?
• Utility
• Is the activity in the question
  disseminated/dispersed across the locality
  geographically?
• Is the activity dispersed among programs?
• Are the results and information derived from
  public health assessment, research, evaluation
  and other activities used to improve public
  health?

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Re-Vote as Needed

• Conduct a second vote when needed.
• Knowing that you may not have total unanimity,
  you can ask those that are not in total agreement
  with the group if they are comfortable moving
  forward if their comments related to system
  strengths and weaknesses are captured by the
  recorder and will inform performance improvement.
  
• Ultimately, the final score doesnt matter as
  much as the quality of the notes to help
  understand the scores and the differences of
  opinions.

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Step 8 Essential Service Summary Discussion

• Remind participants about note-taking space in
  the assessment tool.
• Facilitate reflection with the group on what was
  shared throughout the essential service related
  to strengths, weaknesses, opportunities for
  immediate improvement or partnerships and
  priorities or longer term improvements.
• Solicit a volunteer to share the summary on
  behalf of the group during the closing large
  group session.

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Participant Guide Essential Service Summary
Notes Page
Field Test DRAFT
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Beginning the Process

• Start the process with introductions, including
  the facilitator and recorder, and reviewing the
  ground rules (see Poster 1, above). Solicit any
  additional ground rules. Get agreement on the
  ground rules prior to moving on with the process.
• Find out the groups expectations for the process
  and share what can be met and what needs to be
  tabled for the future.
• Begin in the facilitator role and stay in the
  role throughout the process. A neutral
  facilitator is very important. Participants
  should be doing most of the sharing and talking,
  not the facilitator.
• Ensure all participants seating is comfortable
  with no obstructions in their view for visuals
  and seeing one another.

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During the Process

• Encourage all participants to contribute.
  Emphasize similarities and points of agreement.
  Draw out different points of view.
• Use reflective listening skills.
• Show respect for the process and the experience.
• Point out relevant information in the discussion
  and how it pertains to the Model Standard
• Keep discussion relevant to the Model Standard.
• Try to encourage concrete examples of activities,
  but discourage anecdotes.
• Keep people focused on system as a whole.
• Work to garner buy-in from power players
  without excluding anyone.
• Try to have people frame their discussions in the
  categories of strengths, weaknesses,
  recommendations for immediate improvement, and
  priorities to help the recorder capture thoughts
  in an organized way.
• Never be defensive.
• Keep an eye on the time.

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Practice Active Listening

• Steer people toward expression of their interests
  and values rather than their positions and
  demands. It may be helpful to ask, Help us
  understand why this is important to you?
• Understand that everyone has mixed motives that
  may get in the way of their cooperation.
• Pay special attention to surprise, differences,
  and disagreements.
• Reflective listening validates responses and
  ensures accuracy of meaning.

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Troubleshooting

• Conversation becomes focused on the LHD
• The group feels they dont have enough
  information to answer a question
• Difficulty achieving consensus
• Individuals become defensive about their
  agencies performance
• One person dominates
• The group gets off topic or in the weeds

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Exercise
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If the conversation becomes focused on LHD. . .

• Remind people that this is a system-not an
  LHD-assessment.
• Even though the LHD might have a strong presence,
  it may not be aware of all the activity going on
  in the system.
• Remind people there are often system duplications
  and inefficiencies in how the LHD works with the
  rest of the system that need to be uncovered.

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If the group feels like they dont have enough
information. . .

• Capture what the group does does not know.
• Capture who is missing from the conversation
• Vote on the question knowing the group has
  limited information. Lack of awareness is an
  indicator of system performance.
• Flag the question and revisit after gathering
  more information from missing individuals.
• Step up/step back.

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If the group has difficulty achieving consensus.
. .

• Why do you think we have such a split on this
  particular Model Standard?
• Help me understand why some of you are so
  passionate about this?
• Are some of us voting our positions, or do we
  genuinely see the system this differently?
• Could someone explain to us what experience has
  made you believe that we are failing in this
  area?
• For those of you who scored the activity low (or
  high), could you talk about why you scored it low
  (or high)?
• Why did those of you who scored low not think the
  system should score higher? Why did those of you
  who scored high not think the system deserved to
  score lower?
• What would make the no person vote moderate
  activity or the optimal person vote significant
  activity?
• Once new information has been shared, it often
  increases understanding and causes some rankings
  to change. Asking the following question is a
  good next step  
• Given this new information, how do we think the
  system as a whole is functioning?

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Handling disagreement. . .

• Let the participants who have contradictory views
  explain their answers.
• The following questions can help resolve
  disagreements
• Why do you think we have such a split on this
  particular Model Standard?
• Help me understand why some of you are so
  passionate about this?
• Are some of us voting our positions, or do we
  genuinely see the system this differently?
• Could someone explain to us what experience has
  made you believe that we are failing in this
  area?
• For those of you who scored the activity low (or
  high), could you talk about why you scored it low
  (or high)?
• Why did those of you who scored low not think the
  system should score higher? Why did those of you
  who scored high not think the system deserved to
  score lower?
• What would make the no person vote moderate
  activity or the optimal person vote significant
  activity?
• Given this new information, how do we think the
  system as a whole is functioning?
• After discussing differences and validating
  everyones opinion, ask Is there anyone who
  cannot live with this rating? If there is
  significant dissension, offer to make a note on
  the flip chart for possible reconsideration later
  or to help determine if there is a pattern to the
  groups disagreements.
•  After further discussion, take another vote.

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If there is defensive about agencies
performance. . .

• Use reflective listening to validate their good
  work while reminding them that this is a system
  assessment, and their strengths can be leveraged
  to improve the system overall.
• Remind them there is always room for improvement,
  and they are rating the system against optimal,
  not minimal standards.

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If one person dominates. . .

• Use reflective listening to validate their point
  and ask others for their opinion.
• Round robin works well to allow everyone to
  respond in an orderly manner. Start round robins
  with different people so the same person doesnt
  have the first or last word each time.
• Reference ground rules.
• Remind people this is a system assessment, not an
  assessment of one agency.

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If the group gets off topic. . .

• Use reflective listening to validate the
  importance of the conversation.
• Confirm the recorders took note of what was
  discussed.
• Use a parking lot.
• Reread the question, and remind participants of
  their goal

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Recording Process/Tips
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Recorder Roles

• Capture Quantitative Results
• Scores
• Capture Qualitative Data
• Key ideas and comments from the discussion
• Information that shapes group scores (reasons for
  high/low performance)
• Systems strengths and weaknesses
• Potential strategies for improvement
• Priorities

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Additional Recorder Responsibilities

• Help the facilitator count votes (if using voting
  cards)
• Assist the facilitator to manage time
• Serve as a liaison to the meeting coordinator

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Recorder Tips

• Two recorders per room is optimal.
• Seat recorders together.
• Provide a standard set of abbreviations.
• Consider using flip charts or a laptop/projector
  so that participants can view recorded responses
  and comments.

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Recorder Process

• Step 1 Capture Participant Names and
  Organizations
• Step 2 Capture Partner Contributions to Overall
  Essential Service
• Step 3 Capture Discussion Points Regarding
  Partner Contributions for each Model Standard
• Step 4 Capture Participant Comments/Discussion
  Points in Response to Discussion Questions
• Step 5 Capture Participant Comments Scores
  for Performance Measures
• Step 6 Capture Participant Comments Scores for
  Agency Contribution Questions (optional to
  complete)
• Step 7 Provide Summary Comments on the Essential
  Service

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Discussion Points
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Resources

• NPHPS Online Toolkit at http//www.cdc.gov/NPHPSP/
  index includes
• Assessment Instruments, Model Standards, User
  Guide
• Sample preparation, assessment, performance
  improvement materials from users
• MAPP www.naccho.org/topics/infrastructure/MAPP/in
  dex.cfm
• NPHPSP Monthly User Call Series contact Jennifer
  McKeever at jmckeever_at_nnphi.org or 202-842-2022
  for more info
• For technical assistance or to order materials
• 1-800-747-7649 or phpsp_at_cdc.gov

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Q and A
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Contact Information

• Laurie CallIllinois Public Health
  InstituteLaurie.Call_at_iphionline.orgSpringfield
  Office 217.679.2827Chicago Office
  312.850.4744
• Teresa Daub
• Centers for Disease Control and Prevention
• tdaub_at_cdc.gov
• 404-498-0317