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)

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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

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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

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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

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

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Essential ServiceDescription

•Includes list of potential system partners for each Essential Service

Field Test DRAFT

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Model StandardDescription

•Uses plain language

Field Test DRAFT

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Model StandardDiscussion 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

Facilitation Process

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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/)

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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.

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…

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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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• 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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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.

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Participant Guide

Essential ServiceDescription

Field Test DRAFT

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Participant Guide

Model StandardDescription

Field Test DRAFT

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 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.

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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

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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.

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

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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

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

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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/index.cfm

• NPHPSP Monthly User Call Series: contact Jennifer McKeever at jmckeever@nnphi.org or 202-842-2022 for more info

For technical assistance or to order materials: 1-800-747-7649 or phpsp@cdc.gov

Q and A

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Contact InformationLaurie CallIllinois Public Health InstituteLaurie.Call@iphionline.orgSpringfield Office – 217.679.2827Chicago Office – 312.850.4744

Teresa DaubCenters for Disease Control and Preventiontdaub@cdc.gov 404-498-0317