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National Public Health Performance Standards Program
Local Public Health System Assessment, Version 2

Assessment Meeting Guide: Information for Facilitators

The more guidance facilitators can give participants, the less likely they will feel frustrated with the process. Because participants are charged with completing the assessment collectively as a group, they need some direction. This document is designed to walk facilitators through the process while highlighting potential challenges and providing guidance on how to overcome obstacles. Facilitators should review this entire guide at least a week before facilitating an NPHPSP Local Instrument Assessment and should refer to it during instrument completion. This guide should be used in conjunction with the NPHPSP Users Guide so that facilitators have a better understanding of the purpose of the NPHPSP before facilitating the process. If you have questions, please do not hesitate to contact NACCHO staff for assistance at mapp@naccho.org.

Facilitation Issues to Address before Convening System Partners

Several issues should be addressed by facilitators and organizing staff before completing the assessment. If your system is using a multi-group process that requires more than one facilitator, it is important to ensure facilitator coordination to limit variability among group processes. Coordination will result in more reliable assessment results. Facilitators should also discuss, prior to the day of the assessment, how they will address each of the following issues:

• H

  Facilitator Responsibility in a Consensus Process:

  • To ensure that the concerns of everyone in the room are met

  • To keep the process moving

  ow will voting take place? Different methods for voting include the use of voting cards, raised hands, and electronic voting tools.

• How long will each member be allowed to voice their opinion? For example, facilitators may limit discussion to 15 minutes at the beginning of each Model Standard and one minute in the voting phase of each question.

• How will consensus be reached? It is important to remember that consensus building is defined as overwhelming agreement. This is not the same as unanimity, nor is it majority rule. As a facilitator, you should encourage participants to go as far as possible to meet the interests of all participants.

• How much systems activity is enough in deciding how to vote? Discuss perspectives on:

  • Isolation: If one system partner indicates that his or her organization provides a particular public health service, but no one else in the system is aware of the activity, should the group score the measure as “significant” or “optimal” activity?”

  • Participation among many system partners: Is the service provided in one sector of the public health system and not in others (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? Or, are several sectors providing the same service creating redundancies in the system?

  • D

    Potential Challenges:

    • Participants want more time to discuss questions

    • Participants do not believe they have enough information to vote

    • Participants have different definitions of what “meeting the standard” means

    • Some participants may question the subjectivity—and therefore the validity—of the assessment

    • Certain questions are not clearly understood by the participants

    • A few participants dominate the discussion

    • Supervisors at the table make it uncomfortable for their staff to provide candid view points, or staff may defer to the boss rather than offering their own perspectives

    ispersion: Is the activity in the question disseminated/dispersed across the state or locality geographically, or does it exist in only one area? 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.

  • Frequency: Is the activity in question done routinely or on an ad hoc basis?

  • Quality: Is the activity in the question done in a high quality manner? Perhaps it is a new activity that still needs quality improvements.

• How will the discussion boxes be incorporated into the discussion? If only some of the items in the discussion box have been addressed, how will the discussion box influence the final decision? If only some of the discussion boxes were used, how will that influence overall voting and scores?

• When and how will the agency specific and priority setting questions be answered? These questions can be answered at the end of each Essential Service or all at once. It is recommended that the agency specific questionnaire be completed by the local health department at a later date or completed at the end of each Essential Service by the corresponding group. The priority setting questions should be addressed by all participants after all ten Essential Services sections have been completed.

• What ground rules should be established? A few ground rules are included below. Additional ground rules can be created based on the anticipated dynamic of your group(s). Ground rules help ensure a safe environment for consensus and an efficient and fair process.

Preparation Before the Meeting

As a facilitator, you should have a clear understanding of the instrument content and assessment process. Before the assessment process begins, you should:

1. Review the Essential Services chapters you will facilitate.

2. Identify terminology that may be challenging for participants, keeping in mind that the assessment may include some public health jargon unfamiliar to non-traditional public health partners. Use your own knowledge of public health to define these terms. If you are not a public health professional, use the NPHPSP glossary and talk with your local health department staff contact.

3. Identify instrument questions that may be confusing for participants. Discuss them with others in charge of organizing the assessment and improve your understanding before the assessment begins.

4. Have a clear understanding of the voting and consensus processes, which includes the answers to the facilitation questions posed in the section above.

Day of the Meeting

Participants should already have a good understanding of why they are in the room and how they contribute to the local public health system. Nevertheless, you will need to reiterate throughout the meeting that the process is assessing the “system” and not a particular agency.

S

Process:

• Review Essential Service Model Standard (3 min. recommended)

• Answer participant questions about the Model Standard when clarification is needed (5 min. recommended)

• Discuss what each organization does with regard to the model standard. Remember to capture this discussion (15 min. recommended).

• Begin answering the questions. When consensus cannot be reached, identify the barrier. Use the discussion boxes to help answer the relevant questions (30-60 min. recommended).

TEP 1: Introductions. To begin your group session, introduce yourself, your Scorer, your Recorder(s), and your Technical Advisor, and describe your roles. Ask all breakout group participants to introduce themselves. State that the purpose of the group’s work is to assess the extent to which the local public health system meets or does not meet optimal performance standards.

STEP 2: Ground Rules. Review the ground rules and ask if they would like to add others.

• Commitment to the process: Even though the instrument may seem subjective, it has been tested for validity and reliability. However, the instrument is only as valuable as the effort each person contributes. Willingness to share knowledge and be truthful about both accomplishments and limitations will ensure a good assessment of system capacity. The Local Public Health System Assessment is a quality improvement tool and should be used to help the system improve. The level of quality improvement is predicated on how well the participants are committed to the process.

• No Judgment: Remind participants that the purpose of the assessment is to get an honest and accurate perception of the strengths and weaknesses of the system, which will help with quality improvement initiatives. Participants and/or organizations are not being judged by their answers.

• All perspectives are valued: Each individual has a different point of view regarding the strengths and weaknesses of the system. It is important to hear everyone’s perspective and vote based on the collective understanding of the system after discussion. Voting should not be based solely on individual experiences. Everyone should listen to all perspectives to understand the “system’s” level of functioning.

• Time: Completing the assessment takes time. In order to keep a balance between sharing experience and perspectives and getting through the instrument, it is important to keep discussion short and relevant to the Model Standard.

• Perspective: Although each partner is valued as an individual, the desired end result is to gain understanding about the system as a whole. Participants should vote according to the system and not their own individual efforts.

STEP 3: Review Materials

Each participant receives:

• Essential Service Assessment Chapter(s) that the participant will be discussing

• Priority Questionnaire

• Agency Questionnaire

• Voting Cards

(These materials are available online at www.cdc.gov/od/ocphp/nphpsp.)

Each table should have a:

• Note taker to capture discussion. (Notes can be displayed on the wall or a flipchart so everyone can see what is being captured.)

• Recorder’s Score Sheet for the selected essential service (1 copy per table).

• User’s Guide, which may not be necessary, but participants might be interested.

• Glossary for reference throughout the assessment. System partners may not be familiar with all the terms used in the instrument.

• Response Scale to remind participants when it is time to vote. This describes the voting response options voters will use when answering questions. (Point out that you will describe the scale in detail once the group is ready to begin voting.)

• Printed list of all 10 Essential Services. The Essential Services presents the framework for the NPHPSP by describing the activities that should be provided by the public health system.

In the Room:

• The Public Health System picture emphasizing all the different sectors comprising the system as a WHOLE. This perspective will remind participants that the instrument assesses the entire system and not just the organizations they represent. You may want to remind participants of the system perspective periodically throughout the process.

STEP 4: Review the Process. Provide an overview of what will happen.

State:

1. You have been assigned X “Essential Service.”

2. I will read aloud the Essential Service and related activities you will be discussing

3. (Review the Assessment Instrument) There are 2-4 model standards, which represent major activities or practice areas for each Essential Service. Each model standard includes:

• A description of optimal performance for a public health system to achieve the standard.

• Questions related to the model standard (the number of questions may be few to many) that serve to measure how that standard is being met.

4. We will then review some of the activities various organizations are doing to contribute to meeting this standard; talk about what we do collectively as a public health system in meeting this standard; and what should be occurring that is not. We will then vote on each question related to the model standard.

5. We will have a recorder to document key messages we want to take away from our discussion. These may include but are not limited to: strengths and weaknesses of the LPHS related to this Essential Service; recommendations for immediate improvements of the LPHS related to this Essential Service; and any priorities of the LPHS related to this Essential Service. As we have our discussions, try to focus your answers around these themes to help the note taker.

STEP 5: Implement the Assessment:

PART 1: The Discussion. The first part of implementing the assessment is the discussion. This is when participants learn from each other about what the system is doing to address each model standard.

1. Read the Essential Service and corresponding activities.

2. Ask the group to take a few minutes and think about how their organizations or other organizations they are familiar with contribute to meeting the standard.

3. Read the first model standard and its description.

4. On the first time through, ask participants to skim the assessment questions under the Model Standard pointing out that the assessment questions mirror each of the items in the Model Standard.

5. Discuss the Model Standard and allow 10-15 minutes for discussion. Begin by allowing each participant the opportunity to share with the group what his/her organization does related to this standard. Allow participants to “pass.” Limit sharing time to 3 minutes for each person.

6. Discussion is over when 1) the facilitator determines enough time has been spent on the discussion, or 2) there seems to be no further discussion needed.

Keep In Mind:

• Encourage all participants to contribute.

• Draw out different points of view.

• Keep discussion relevant to the Model Standard.

• Keep people focused on system as a whole.

• Try to encourage concrete examples of activities, but discourage anecdotes.

• 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.

PART 2: Voting. Once the overview discussion is complete, it’s time to begin voting.

1. Make sure each participant has six colored cards representing each response option and a discussion card. Review what each card represents according to the response scale (which should be in the middle of the table for easy reference).

NO ACTIVITY	0% or absolutely no activity.
MINIMAL ACTIVITY	Greater than 0%, but no more than 25% of the activity described within the question is met within the public health system.
MODERATE ACTIVITY	Greater than 25%, but no more than 50% of the activity described within the question is met within the public health system.
SIGNIFICANT ACTIVITY	Greater than 50%, but no more than 75% of the activity described within the question is met within the public health system.
YES / OPTIMAL ACTIVITY	Greater than 75% of the activity described within the question is met within the public health system.

2. Reiterate some basic parameters in thinking about how well the public health system is functioning. If you are using the subgroup approach, remember it is important to ensure a coordinated approach to facilitation. The discussion process in your group should parallel the other group processes. Share the following parameters with participants:

   • Isolation: If one system partner indicates that his or her organization provides a particular public health service, but no one else in the system is aware of the activity, should the group score the question as “significant” or “optimal” activity?”

   • Participation among many system partners: Is the service provided in one sector of the public health system and not in others (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? Or, are several sectors providing the same service creating redundancies in the system?

   • Dispersion: Is the activity in the question disseminated/dispersed across the state or locality geographically, or does it exist in only one area? 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.

   • Frequency: Is the activity in question done routinely or on an ad hoc basis?

   • Quality: Is the activity in the question done in a high quality manner, or is it a new activity that still needs quality improvements?

3. Read the first stem question under the Model Standard. Remind participants that the stem question relates back to the Model Standard.

   • Participants can vote on the stem question and subquestions in the order the appear, or alternatively, can vote on subquestions before the stem question. (When answering a question that includes a discussion toolbox, facilitators should encourage participants to consider the elements listed in the toolbox.)

   • Afterwards, ask if anyone wishes to have further discussion on this specific question.

Note: Some questions include a discussion toolbox, containing specific elements or characteristics associated with optimal performance, which may be used as checkboxes or prompting points to inform responses to the preceding assessment question.

4. Are we ready to vote?

   • Begin moving through the questions and ask participants to cast their votes.

   • After participants vote, read aloud the result (e.g. 5 optimal, 7 significant activity, 3 moderate activity)

5. Work through all the questions related to the first model standard. Do not move onto the next model standard until your group has completed the entire standard.

6. 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.

• 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?

  • C

    Listening: An Essential Skill

    • Steer people toward expression of their interests and values rather then 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.

    ould 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.

7. Work through all the questions in the first model standard. Move on to the next model standard until you have completed all the Model Standards in the Essential Service.

Keep In Mind:

• Encourage voting without discussion of the assessment questions

• Emphasize similarities and points of agreement

• Point out relevant information in the discussion and how it pertains to the Model
  Standard

• Keep an eye on the time. You have approximately 1 hour to complete the assessment for each Essential Service with a 15-minute break at a time determined by the group.

EXTRAS: At the end of each Essential Service, there is an optional Agency Contribution questionnaire, which helps identify the extent to which the LHD contributes to a particular Essential Service. Determine prior to the meeting if the organizers would like you to go through this questionnaire during the assessment process or if the LHD will complete that portion of the assessment separately.

Step 4: Wrap Up

At the end of the voting process, review the take away messages that have come up during initial and further discussions. Fill in any new information related to:

(1) Strengths of the LPHS related to this Essential Service.

(2) Weaknesses of the LPHS related to this Essential Service.

(3) Recommendations for immediate improvements of the LPHS related to this Essential Service.

(4) Any priorities of the LPHS related to this Essential Service.

End the session by asking participants if they learned anything new about activities the system is performing.

Facilitator’s Guide - 8 - NPHPS Local Instrument – V2