MCH Needs Assessment: Capacity to Competency Donna J. Petersen, ScD, MHS MCHB Partners Meeting February 26, 2009

Imagine this... A state MCH program produces an elegant needs assessment filled with tables and tables of data but there is little analysis, little stakeholder input and no discussion of what the state might do about the problems suggested by the data

Imagine this... A state MCH program produces an elegant needs assessment complete with data and information gleaned from constituents with clear areas of focus identified but the state priorities bear little relation to these areas of need and instead look suspiciously like the organization chart of the state MCH program

Imagine this... A state MCH program produces an elegant needs assessment complete with quantitative and qualitative data, a full analysis of the nature and scope of needs, a set of priorities clearly derived from this analysis, but no change in structure or function of the central office, no change in resource allocation, no clear plans to engage in any new efforts

Do we have to imagine this? Have any of us been in these situations? What do these have in common?

One thing, I would argue, is that they possibly reflect a lack of capacity to engage in the full range of activities related to needs assessments, from gathering and analyzing data, to engaging constituents, to setting priorities, to devising plans to action, to acting on those plans in meaningful ways

Needs Assessment in MCH We recognize That our mission as MCH professionals is to secure for the families in our states all that they need to develop, grow and thrive That we shape this mission by pursuing information on the nature of those needs That needs are revealed both through data collection and through open discussion, listening and observation

Needs Assessment in MCH We further recognize That the authors of OBRA 89 put in place a mechanism to assure we had the means to conduct comprehensive needs assessments But that needs assessment is an ongoing, continuous process, not just every five years AND, that that process does not stop with the compilation of needs but with the articulation of priorities and the development and execution of a plan of action

Needs Assessment... Since 1989, we collectively have made tremendous progress in our ability to collect, analyze, manage, disseminate and optimize data and information Most state MCH programs now have expert staff, data or policy analysis units, data sharing agreements with other agencies, automated collection systems for our grantees and partners, and a system for qualitative information gathering

... to Action in MCH... to Action in MCH Where we have difficulty is in Identifying strategies to combat problems Achieving consensus on direction Making the tough decisions Garnering political will Managing change Executing the plan of action

Why is This Difficult? Over-committed staff Over-committed staff Lack of political will Lack of political will Committed to present activities Committed to present activities Previous planning failures Previous planning failures Limited expertise Limited expertise No readily available solution No readily available solution Insufficient resources Insufficient resources Competing priorities/desires Competing priorities/desires thanks, Bill Sappenfield

Disconnect between Desire and Reality Perhaps the biggest challenge we face is reconciling the vision - the wishes and hopes generated by a comprehensive needs assessment - with the practical reality of what we actually have the ability to accomplish

A Need does not a Priority make If youve been with me before, youve heard me champion the idea that you must have a solution to address an identified need that you believe may work, that wont cost you the bank and that will be acceptable to the public and to policy makers Without a reasonable strategy there is little point in selecting the need as a priority...

New Step in the Needs Assessment Process? Perhaps in addition, we need to more deliberatively assess, as part of our comprehensive assessment of needs, our ability to achieve the dream the elasticity of our resources the level of political will that exists for change our true ability to adapt to a new direction Even where a solution exists!

Opportunities... We dont always take them Why? Because were pragmatic If you have no one to nominate to the new task force on x, youll decline If you have no one with the right expertise to write the grant, you wont apply If you know you cant act on the promise, you wont make the promise Its a matter of capacity

Capacity Capacity The ability to hold, receive, store or accommodate A measure of content Maximum production or output Legal qualification, competency, power or fitness Power to grasp and analyze ideas and cope with problems Position or character assigned or assumed

Capacity Assessment What, in the starkest light of day, can we really do to move in a new direction? How can we objectively assess our reality? How do we measure our capacity for success? Our ability to accommodate Our competency and fitness Our power to cope with change Our positional authority

Capacity Assessment 101 This would be a whole lot easier if there was some kind of guidebook that clearly stated what every state MCH program should look like But it is one of our great strengths that we are allowed to organize and function in response to the needs and circumstances of our states if youve seen one MCH program, youve seen one MCH program

Capacity Assessment The tremendous variability in our states... geographic, demographic, historic, economic, social and cultural, environmental, behavioral, etc adds to the complexity of attempting to characterize sufficient capacity for a state MCH program Not to mention the different ways we choose to structure our state governmental agencies

Capacity Assessment Where is MCH in the health department hierarchy? Is CSCHN with MCH or somewhere else? What else is aligned with MCH? Family planning? WIC? Immunizations? Lead? Injury prevention? Tobacco? Mental health? School health? Home visiting? Substance abuse? What else is/is not within the health department? Where is Medicaid? Early Intervention? Environmental health?

Capacity Assessment Like everything else we do, this we do not do alone in isolation We are masters at building partnerships, forming coalitions, persuading others to do what is right for children and families, seeking and securing support for our broad efforts So lets think about what we need in order to better meet the needs of our populations

Capacity Assessment Internal to the central office 2. Within the home agency 3. Within related state agencies 4. Within local jurisdictional offices 5. Within local communities – Usual suspect partners – Non-traditional partners 6. Within decision-making bodies

Capacity Assessment 101 What are you looking for? 1. Skill sets 2. Resources (money is not the only currency) Time Talent Support/Partners/Infrastructure 3. Interest

First Exercise SKILL SETS – Think about the skill sets you would like to have in your ideal state MCH central office – Dont worry about the number, just brainstorm the skills you would like to have available to you – Think about the entire needs assessment process (which, we have already established, is in effect your entire program planning,advocacy, implementation, evaluation, communication process for MCH activities in your state)

First Exercise Think of these as fixed assets, skill sets you need regardless of the direction of your programs Feel free to advocate for what you believe while imagining the ideal team DO NOT worry about where these will come from Select someone at your table to report back your consensus conclusions

Skill Sets Report Back

If you dont have these skill sets in the MCH central office, where else might you find them? First think about your governmental partners Other units within your agency? Other state agencies? Local agencies? Then think about other partners Grantees? Community organizations or groups? Academic institutions?

Second Exercise Now we have to get a little real... Brainstorm for awhile where you might find the skill sets you identified Think first about whether it even exists, where, and then rate your ability to gain access to it Relatively easily, maybe, probably not Is training available in the skill set? Select a different reporter from the table

Sources of Skill Sets Report Back

Capacity Assessment Note that we have made no attempt to link these desired skill sets to any particular set of needs, or programmatic initiative Thats because you need to know the full menu of possible assets in order to determine whether you have the capacity to respond to a particular challenge Needs change, your efforts will change, your capacity to change will change...

Capacity Assessment: Resources Resources – Yes, it would be lovely to have more money And you should definitely be thinking about that as you evolve your plans in response to needs and your growing knowledge of your capacity to respond Who might fund this? The legislature? A federal agency? A national foundation? A local foundation? Can you partner with another agency who may fund portions of the effort? The big question: Can you stop funding something else in order to fund this?

Resources Also important to figure out where any extra time may be stashed away... This refers to your own staff Others with the skill sets you need Local grantees Community partners Do you have capacity where you no longer have need? You may have skill sets that are no longer relevant C H A N G E... is really hard

Delivery or Deployment Capacity Do you have networks through which you can deploy new initiatives? Do you have local agents? Do you have accessible media markets? Do other agencies have local offices? Can you work through schools? Through health care providers, hospitals, clinics? Are there academic institutions outside the metro areas?

Resource Inventory Identify local service delivery capacity Reveal gaps in services from lack of availability, access, continuity, appropriateness Reveal underutilized capacity as well Help you clarify who is currently or potentially capable of meeting the service delivery needs you have identified, typically at the local level

Resource Inventory These can be conducted in several ways Via a survey (paper, telephone, on-line) Via an audit Via information provided at the time of application for funding or preparation of an annual report (for those agencies you fund)

Resource Inventory Typically want to learn: Type of services offered To what client mix At what level of intensity (quantity) At what level of coordination across providers With what type of follow-up At what cost (or eligibility limits) At what location, over what hours By what types of providers

Resource Inventory Coupled with a good assessment of need, resource inventories help fill in your capacity map or are part of an assets inventory These inventories can give you clues into not only where you might have obvious gaps but also where you might have potential to add a service, link services, or modify client/service mix

Changing the Resource Inventory If you find areas in need of enhancement the next question is, of course, how do you get these agencies to change what theyre doing Remember, they dont like change any more than you do

Change If you fund them, you may have some leverage Best not done without some serious conversation They will surprise you if you give them a chance to help you work through these issues Often better done as a carrot and not a stick, i.e. if you will do x, I will also let you do y (or stop doing z, which theyve never liked)

Change If they are somehow accountable to you (the royal you in this case) you might be able to back into it by changing the performance measures If they are told they must achieve a certain level of performance or reach a certain outcome, they will have to adjust their efforts to accomplish that Again, better done as a carrot, i.e. reward them for doing it rather than punishing them for not

Change A little bit of money goes a long way If you have no other authority, trying offering some funding, either seed funding through a competitive mechanism, or a small amount of planning money to get something going i.e., $1 per birth in a county or locality to gather information, analyze it and develop a plan to improve pregnancy outcomes

Case Exercise

Case Exercise Report Back

Capacity Assessment: Interest Policy theorists and analysts often speak of policy windows, i.e. the moment of opportunity when a policy agenda has the greatest likelihood of being adopted They also speak of the softening up process and suggest that the time-lag between when an issue is clearly identified and when action is actually taken, can be quite long indeed

Capacity Assessment: Interest Kotelchuck and Richmond wrote of three necessary elements for policy action: Knowledge base (data, science) Effective strategies Political will

Capacity Assessment: Interest Part of your capacity assessment has to be judging the relative political will for action around the issue(s) you have identified Part of this depends on the issues themselves – What issues might be more difficult to champion? Part of it depends on competing priorities – Is something else going on that detracts attention from your issues? (gee, does this ever happen?!)

Capacity Assessment: Interest But part of it also depends on how prepared you are to seize a policy window Have you accumulated sufficient evidence, both scientific and political, to support your agenda? Have you sustained a coalition of support? Have you engaged in that softening up process using your ability to educate and inform elected officials? Are you on the look-out for those focusing events that draw attention to your issue?

Capacity Assessment: Interest So, interest refers to the willingness of elected officials to support your agenda and perhaps stick their necks out But before this, it also speaks to the interest of the public (the sine qua non of your ability to label something a true need) AND the interest of those you work with, partner with and fund

Capacity Assessment: Interest Thankfully, these all come together as part of the usual suspect needs assessment efforts you have been putting forth for nearly 20 years You know the data alone does not indicate need You know you need to engage your constituents You know you need to form strong stakeholder coalitions to move the full agenda forward You know to gauge the political will on the issue

Capacity Assessment: Interest So while this may have seemed the most difficult to get a handle on, it may in fact be easier Its a test of your political savvy to know when the winds are blowing for change and to seize those moments The challenge, interestingly enough, usually is back home at the office

Capacity for Internal Change Managing change within your team is a huge task for leaders (An aside)leaders really only do two things: – They set organizational direction, – And they create organizational culture. Guess which is more important? Pete Ginter, PhD, MCH Leadership Skills Training Institute, 2008

Capacity for Change = Organizational Culture Organizational culture: the attitudes, experiences, beliefs and values of an organization the values and norms that are shared by members of an organization and that control how they interact with each other and with stakeholders outside the organization Is yours a change-ready culture?

Change-Ready Culture Strong Culture where staff respond based on their alignment to organizational values and where people do things because they believe it is the right thing to do Weak Culture where there is little alignment with organizational values and control must be exercised through extensive procedures and bureaucracy

Culture, Change and Leadership Culture is nurtured through leadership, therefore: We need leadership to effect change! Formulate a clear strategic vision Display top-management commitment Model culture change at the highest level Modify the organization to support cultural change Select and socialize newcomers and terminate deviants Be sensitive to tensions between organizational and individual interests

Capacity Limitations What do you do when you run into a wall? Obviously you cant take on more than you are capable of doing If you cant get the skill sets you need internally or through your partnerships If you cant identify resource opportunities If there is insufficient interest These issues need to go on a back burner (remember the softening up process)

When Priority and Capacity Collide You will identify needs that are not yours to act on, e.g. housing, jobs, crime You will identify needs that are yours but for which no good solution has yet been found effective, e.g. early preterm birth, obesity, meth You will identify needs that are yours that have a solution but for which you have no capacity, i.e. no local network, no skills, no time, no will

What to do? They remain priorities because they emerged from your needs analysis but they require a different kind of response The first set requires an advocacy response – only you know how effective you might be The second set requires a data or research strategy... again, only you know if you have those skills or contacts The third set requires infrastructure changes

Capacity as Priority NEVER be afraid to include capacity needs in your top priorities! Once youve done this assessment back home, you should be able to articulate areas of lesser capacity that must be shored up if you are to effectively address the population needs you have identified It is not wrong to include in a list of priorities the need to improve your basic infrastructure

Do the Best You Can Remember the perfect is the enemy of the good? Everything is the enemy of something Better to do a few things well, than a lot of things poorly or not at all And better to be honest about what you can do and what it would take for you to do more

Capacity for External Change We have focused on the State MCH program and your more or less direct sphere of influence As we know, our responsibility extends to the entire system that supports families in our communities As such, part of our capacity assessment has to focus on the extent to which that system exists and is both enduring AND flexible

What is the MCH system?

System Capacity Woven throughout what weve discussed is the need to attend to this – Where are your partner agencies? What could they be doing differently to support families in your state? Where are there huge gaps around which you might advocate together? Do you have sufficient local capacity? What about health manpower in the state?

Conclusions Priority/NeedSkill Sets in the Central Office Local Network/ Service Delivery Partners/ Resources Political Will/ Interest Teen Pregnancy Prenatal Depression Physical Fitness in Children Partner Violence HPV Vaccine

2010 Block Grant Needs Assessment To thine own self be true You must know yourself, your strengths and your limitations before you can effectively fulfill your MCH responsibilities I encourage you to consider assessing your capacity while you are assessing your needs And to be realistic when setting your priorities They can and should include steps to address both population needs and capacity needs

Good luck and Godspeed We are ALL counting on you Thanks for your generous attention