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Facilitating the NPHPSLocal Instrument
Laurie Call, Illinois Public Health Institute
Teresa Daub, CDC
Learning ObjectivesFollowing 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.
Overview of the National Public Health Performance Standards
(NPHPS)
3
NPHPS VisionA partnership effort
to improve the quality of
public health practice and
performance of public health systems
NPHPSThree Assessment Instruments
– State public health system– Local public health system– Local governance
Partners– CDC– APHA– ASTHO
– NACCHO– NALBOH– NNPHI– PHF
Framework of the NPHPS
6
Four Concepts Applied in NPHPS
1. Based on the ten Essential Public Health Services
2. Focus on the overall public health system
3. Describe an optimal level of performance
4. Support a process of quality improvement
Public Health System
Schools
Community Centers
Employers
Transit
Elected Officials
Doctors
EMS
Law Enforcement
Nursing Homes
Corrections
Faith Institutions
Civic GroupsCivic Groups
Non-Profit Organizations
Neighborhood Organizations
Laboratories
Home Health
CHCs
Hospitals
Tribal Health
Drug Treatment
Public Health Agency
Mental Health
Fire
Stimulate Quality Improvement• Standards should
result in identification of areas for improvement
• Link results to an improvement process
Plan
DoStudy
Act
MAPP (Mobilizing for Action through Planning and Partnerships)
NPHPS Local Materials
10
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
Version 2 Instrument Format
ModelStandard
Essential Service
Version 2 Instrument Format
DiscussionToolbox
Measuresor Questions
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
15
Essential ServiceDescription
•Includes list of potential system partners for each Essential Service
Field Test DRAFT
16
Model StandardDescription
•Uses plain language
Field Test DRAFT
17
Model StandardDiscussion Questions and Performance Measures
•More discussion•Fewer scored questions
Field Test DRAFT
18
Essential Service Summary Notes Page
Framework for identifying:•Strengths•Weaknesses•Opportunities•Priorities
Field Test DRAFT
Facilitation Process
19
General Principles of FacilitationFacilitators…• 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/)
20
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.
Facilitation ProcessStep 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
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
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)
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
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
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
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
Discussion AreasWhat 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.
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…
30
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?
31
• 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?
32
When voting, think about the focus of the question in terms of:
Public Health System
Schools
Community Centers
Employers
Transit
Elected Officials
Doctors
EMS
Law Enforcement
Nursing Homes
Corrections
Faith Institutions
Civic GroupsCivic Groups
Non-Profit Organizations
Neighborhood Organizations
Laboratories
Home Health
CHCs
Hospitals
Tribal Health
Drug Treatment
Public Health Agency
Mental Health
Fire
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
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.
37
Participant Guide
Essential ServiceDescription
Field Test DRAFT
38
Participant Guide
Model StandardDescription
Field Test DRAFT
Exercise
39
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.
41
Participant Guide
Model StandardDiscussion Questions and Performance Measures
Field Test DRAFT
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.
Step 7:Consensus 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…
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?
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 doesn’t matter as much as the quality of the notes to help understand the scores and the differences of opinions.
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.
47
Participant Guide
Essential Service Summary Notes Page
Field Test DRAFT
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 group’s 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.
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.
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.
Troubleshooting• Conversation becomes focused on the
LHD• The group feels they don’t 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
Exercise
52
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.
If the group feels like they don’t 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.
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?
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 everyone’s 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 group’s disagreements.
• After further discussion, take another vote.
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.
If one person dominates. . .• Use reflective listening to validate their
point and ask other’s 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 doesn’t have the first or last word each time.
• Reference ground rules.• Remind people this is a system assessment,
not an assessment of one agency.
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
Recording Process/Tips
60
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
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
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.
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
Discussion Points
65
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/index.cfm
• NPHPSP Monthly User Call Series: contact Jennifer McKeever at [email protected] or 202-842-2022 for more info
For technical assistance or to order materials: 1-800-747-7649 or [email protected]
Q and A
67
Contact InformationLaurie CallIllinois Public Health [email protected] Office – 217.679.2827Chicago Office – 312.850.4744
Teresa DaubCenters for Disease Control and [email protected] 404-498-0317