DONNA J. PETERSEN: Cassie said we were in Atlanta last week, and in Atlanta we gathered together the states from region 4, it’s one of the bigger regions, so they were perhaps a more homogeneous group. This group, regions 1, 2, and 3, spans from Maine all the way down to Virginia, West Virginia, just hearing you introduce yourselves, Pennsylvania, New York, New Jersey, Vermont, New Hampshire, Connecticut, I’m sure I’m forgetting people but that’s quite a range, we’ll have plenty of time to talk amongst ourselves. I view my role here as more of a facilitator, you can always learn more from each other, I always learn from you when I participate in these sessions, so I’m delighted to be here. I wanted to remind you of a couple things, that have already been said, but make sure you heard them, one is the fact that the bureau did issue a contract to have somebody review previous needs assessments and try to identify some promising practices.
I think that will be very useful to folks as you work through this process and some preliminary results will be presented at the AMCHP meeting February 28th through March 2nd, 3rd that’s a meeting you’ll want to attend. There are going to be some sessions there. It’s good that we’re starting this now, as Cassie said, it’s not due until July of ’05, but this is a long process, and if done well, it is worth the time spent. This is more of an over view and introduction, we’ll get into some of the nitty gritty today, but view it as a beginning, and there are other opportunities for you to learn more along the way.
The other thing, just to remind you again, that Cassie, Jeff, and other folks
from the DSCH, Division of State and Community Health, Carol O’Toole,
Audrey, folks that you’re familiar with, are available to you as you work
through this. If you have questions, if you want to know about, if you want
to try something new, please contact them, they are there to help you.
The other thing is sort of obvious, but use the time that you have here, at breaks, at lunch, at dinner, to talk amongst yourselves. We’ll have opportunities to learn about each other today, and if you hear something that’s of interest to you, go seek that person out and talk more to them, as I said, it’s an opportunity for you to really learn from each other. We will try to give you lots of chances to do that today.
We will do some small group work, it’ll be a little challenging because we’re packed into this room, but we’ll do our best to get you up, move you around, to give you opportunities to talk amongst yourselves. And this is being taped, I really want to thank the folks at the University of Illinois at Chicago, for coming and doing this for us, and particularly for accommodating me, they were hoping I would stand still in front of this podium, and any of you who know me know that that’s not possible! So, thank you for being kind to me.
What we’re going to do today, and you should have copies of these slides
in your notebook by the way, we are going to go over, just a basic overview,
of what is a needs assessment, why are we talking about this. We’ll spend
a little bit of time as to how we involve stakeholders, because I think its
an essential part of the needs assessment process and it’s one that should
begin early and continue throughout the process, so we’re going to spend
some time talking about that.
We’re going to talk briefly about where we get needs assessment data from. Most of you know that and are doing a good job of that already, but what I learned in Atlanta, was that people still struggle with that public input component, so we’ll spend some time talking about that, if you share that challenge, which I suspect you do, so we’ll spend a little bit of time talking about that.
Then we’ll move into a discussion of needs as they represent values, because that’s really what they are, and we’ll talk a little bit more about that. Then we’ll get into a couple of the challenges that we all face when we’re doing needs assessments. One is how to sort through this potentially endless list of needs that are going to emerge from this process. Somewhere in this you’ve got to set some priorities, you have to make some decisions, and we’ll go through some exercises that will hopefully give you some tools that you can use back home within your states, to try to help sort through that process. The other part of that priority setting process is ‘what can I do about this need?’ So needs are going to emerge, needs are going to be presented to you, you’re going to see them in all the data you’re analyzing, but really, a key question is, if I can’t do anything about it, there’s not a whole lot of sense in me raising it up as a priority, only to then say ‘I don’t know’.
That’s not a good process. For a need to truly emerge as a priority need, there has to be a strategy that is within your capability, your purview, to actually implement, so we’ll work through an exercise that hopefully helps you think through potential solutions to some needs that are identified. And then we’ll sum up with phases in needs assessment. I’m doing that at the end rather than at the beginning because that will serve as a sort of review to what we’ve discussed today. You’re a large group, and I encourage you to please ask me questions, share comments, as we go along, we’ve got all day. I’m also going to try to set you up for tomorrow’s discussion on how to write and use performance indicators, which is really a key component to this whole needs assessment effort, and a key component to your planning strategies for maternal and child health in the state. Lets go!
I always have to put this in its big, broad context. MCH is part of public health. And public health is what we do collectively, as a society, to create those conditions in which we can all be healthy. Public health, then, and MCH by extension, is not something that we as professionals do for people, or to people, it’s something that we do together. And so that really frames the way we approach needs assessment. This notion that we do this collectively, it’s in society’s interest to be healthy. People would prefer to be healthy than not. Stop anybody on the street, they will tell you that. And so, they care about what it is you’re doing because they have opinions and beliefs about what health means to them, what a healthy community is, what it takes to have a healthy community, and so its something that we have to do collectively. We know that MCH is a critical component of public health around the world, not just in this country, and that it really speaks to our collective desire again, to have healthy children, to really work to insure the health and well being of all our children, because it’s in our best interest, as a nation.
Public health, then, and MCH within public health, has some unique characteristics apart from other programs serving mothers and children that we know and work with. We’ll get to this a little later, but I want to point these things out now, one is, that our focus is on the entire population. If you go back to the legislation, if you go all the way back to the Children’s Bureau, this is a constant thread through everything we do, the focus on all women and children, mothers and children, children and families, however you choose to characterize it, the focus is on the entire population. I know that one thing that Cassie and Jeff and I and others have talked about, and this is sort of an ‘out there’ thing, but I’ll throw it out now and we’ll come back to it later, when you report numbers served in your annual reports, which is not really needs assessment but in a way it is, because it’s how we come back, we do our needs assessment, we identify our priorities, we set up performance indicators, then we have to report all this stuff that’s required of us.
There seems to be some, perhaps, confusion over what it is you’re supposed to be reporting, and that’s ok, I think we’ve been working over the years to at least be clear when we report numbers served, what it is we’re talking about. The problem the Bureau faces, is if you change your philosophy about this, and go from reporting, say, the entire population of children, because at one point in your MCH program you have really viewed yourself as serving the entire population so you include all six hundred thousand children in the state, and then a year later you have a different philosophy about what you do, perhaps you’re under different political constraints or new administration and they only want you to count the people you actually touch, so now you’re down to 35 thousand. That looks real strange to folks in the Bureau and it looks particularly strange to folks in congress. It’s a point that we really are about the population, think about that when you’re approaching something like needs assessment, performance monitoring and reporting, but also remember that what you do in the states is part of this partnership with all the other states and with the Maternal and Child Health Bureau at the federal level, moving this MCH agenda along for the nation and keeping congress abreast of why this is such a critical effort.
I’ll come back to that point later but you can keep that in your head. So our focus is on the population. Our emphasis is on prevention, we want to anticipate and prevent those things that could create bad health outcomes, so we’re very interested in primary prevention, we’re interested in secondary prevention, tertiary prevention, but our orientation is prevention. When we do needs assessment, we will, inevitably, be faced with this problem here now, that somebody wants you to respond to, that’s part of the process, but you always want to be reminding people ‘well, what could we have done back here? Yes, we need to address that problem, we understand that, but what could we have done earlier, in a prevention orientation?’ That’s an emphasis that we hold. Our orientation is toward communities. You’re working at the state level, and you have that view, and you will work with state partners, but a lot of what happens in maternal and child health in our states happens at the level of the community, and so we’re always thinking about that.
So, when we talk about needs assessment we’re going to spend a lot of time talking about how we engage our community partners because that’s a really important way that we get MCH done in our state. We focus on systems at the state level, at the community level. So, again, when we’re thinking needs assessments we don’t restrict ourselves to only looking at those things that we do directly, our focus is on the population, it’s on prevention. We have to be looking very broadly at anything and everything that could be affecting the health of children and families, because we’re trying to help move systems along. We’ll come back to these points.
And finally, we are leaders. Maternal and child health is ultimately a leadership role, a leadership effort in our states. We have this broad perspective, our focus is prevention, we work with communities, we’re trying to build systems, we have to exert this leadership role on behalf of the populations we serve, and the way we conduct our needs assessments and our plans, all of these things that you’re doing in preparation for the block grant, can really help you, it can be a vehicle for you to exercise that leadership role, to say ‘I’m going to bring folks together, and be a leader’, and convene people, to try to make sense of all this.
So, this isn’t just something we talk about, the notion of assessment is considered a core function of public health. The Institute of Medicine told us this about 10 years ago, they told us this again very recently, so it’s not just something we do, this is something that all public health agencies are supposed to be doing, and, in fact, they define it that way, that it is the responsibility of every public health agency, in essence, to do needs assessment. That’s what that says, regularly and systematically collect, assemble, analyze, and make available information on the health of communities, and needs assessment, an ongoing function, a core function of public health, as a part of public health, it’s something we should be doing anyway. Those of you who were around back then, you look pretty young so I don’t think many of you were, but when this report initially came out in those three core functions…were any of you around back then? Mike McGuiness went around the country and cheered on the core, remember that?
A bunch of people got together and said ‘we don’t like those core functions, they’re not explicit enough, people don’t understand them’, and so they developed the 10 essential services. What’s nice about these is they really are more explicit, more specific about what it is we so in public health and our friends at AMCHP and Hopkins and other people got together and MCH-ized those for us, so we have 10 essential MCH services, and you’ll see, as we go through these quickly, a lot of what I’ve just said is clearly reflected here, this notion of assessment is not an abstract add-on, it’s something that is a basic part of what we do. Obviously. Assess and monitor. Diagnose and investigate. Inform and educate. Mobilize community partnerships. Provide leadership. All of these things we’ve been talking about are part of our needs assessment process. Promote and enforce laws and regulations. Link populations to needs and services. Assure the capacity of the workforce. Evaluate what we do. It’s the end of that planning loop.
Support research and demonstrations into new and creative ways of addressing
problems. When we do our exercise this afternoon, thinking of new solutions
and strategies, hopefully it will trigger ‘yeah, it’s ok, I can
try new things, I can be innovative and bold, because I have to be.’ Otherwise,
it’s hard for us to move the field forward; it’s an essential service.
For us, this truly is not academic. For us, this is very, very real because you are required, by law, to conduct these needs assessments every 5 years. You have to do it. You are to do comprehensive needs assessments to identify your priorities, to arrange programmatic and policy activity around these priorities, to allocate resources consistent with those priorities, and to develop state performance measures to monitor the success of your efforts. This is right in the law, and its part of that ‘how we work collectively’ toward a national agenda. Your needs assessments are to be population based and community focused, consistent with who you are, with what MCH does.
And again, this isn’t new to us. This has been something that we’ve been doing since 1912 when the Children’s Bureau was first established. In the charter of the Children’s Bureau it was said that this agency would investigate and report on matters pertaining to welfare of children and child life among all classes of our people. That means assessment. That word ‘all’ is there. This notion of monitoring, attending, paying attention to what’s going on, welfare of children and child life, all the way back to 1912, and that’s been a consistent requirement throughout the history of Title 5. We know our mission, in law, again, is to assure the health of all mothers and children. Assurance is another one of those core functions. All mothers and children, again, the focus on the entire population.
If you’re going to take that mission as its written, and really embrace
it, in the spirit of that language, you’ve got to be engaging in ongoing
monitoring and assessment, otherwise you don’t know what’s happening
out there in your communities, its just absolutely essential that you do this.
You’ve got to be monitoring trends and the characteristics of these populations.
Trends in health status indicators. Trends in risk factors. Trends in health
systems attribute. Trends in the availability and the accessibility in quality
of services. You’ve got to know, you have to be the seismograph, the hand
on the pulse, use whatever cliché you like, but we can not fulfill our
mission if we are not actively engaged in these kinds of processes. So needs
assessment really is essential to what we do. It is essential to direct our
program, our decisions, toward the most appropriate programs and policies. It’s
essential for us to be able to achieve our goals in promoting the health of
women, children, adolescents, children with special health care needs and their
families. Huge populations within each of our states. It’s a fundamental
part of any program planning activity. If you don’t do this, you’re
not going to be making the best decisions.
The other thing to remember though, the scary part of this, its ok to think ‘I buy that. I understand that’…here’s where the problem comes in, when you start doing this, when you start assessing needs, looking…you’re talking change. Needs assessment is about change. This is where it becomes a challenge. Its one thing to say ‘Yeah sure, I can do that, I can collect, data but wait a minute, I’m going to learn something from this and that may, in fact, lead me to change what I’m doing. Change direction, change a program, advocate for new policy, change the way I allocate resources. That’s when people get very interested in what you’re up to, what are you up to out there. But it really is, needs assessment is part of an ongoing planning cycle. We assess problems, needs, we assess assets and strengths. We talk ‘needs assessment’ because that’s the term of art that we use, but what we’re really talking about is what’s good in our communities. What do we want to have more of in our communities?
What seems to help families thrive? That’s of interest to us as well seems to help us as well because we need to balance, we don’t want to inadvertently harm something that’s actually been successful, that’s been working well. We develop and implement solutions. We’ll talk more about that later. And the solutions, as I’ve said, might not be within your program. It might be within somebody else’s program. You may have to get in the car, drove across town, and go to another agency and say ‘I’ve learned something that I need to share with you and we need to talk about how to make this change.’ So, the solution is not always within your programmatic efforts, it can be outside. We allocate resources, most of us do, in some fashion, either out to local agencies or through grant mechanisms, so how we do that should be based on our priorities and our needs. We should be evaluating what we do, though that’s always a challenge, isn’t it? Let’s see if I remember this right. Legislature funds new program, you come in the process and say ‘Esteemed members of the community, we want to set aside 10% of this money for evaluation.’
‘Absolutely not! I want this money to go to the people! To the services!’ Has this happened to you? Three years later: ‘well, did that thing work? Did you evaluate it? Where’s the data?’ ‘Well, esteemed members of the community, you wouldn’t let me spend any of that money on evaluation, as you recall.’ ‘I don’t recall anything!’ It’s a challenge. But here’s the trick, if we do needs assessment well, if we put in place the capacity to do this in an ongoing fashion, ongoing monitoring and assessment, we can help facilitate evaluations. We don’t have to set up separate evaluation designs for everything we do. Part of the performance measure discussion you’re going to have tomorrow is about that. What can I measure, at what point in time, as I try to implement a new strategy, or address a new problem so that I can both document my success, my performance, but also evaluate in an ongoing fashion what I do. This is all a loop, it’s a cycle. We monitor performance, and then we go back, because what we learn from those exercises, our evaluations, our performance monitoring, feeds right back to our understanding of what’s going on in communities.
Needs assessments, by their very nature, have to be driven by the data. We’ll talk later about using the scientific knowledge base for policy-making and program direction. That’s a mantra, right? ‘Data driven’. We all know that now. We might not have known that before but we certainly know it now. But, we have to recognize, if you go back to what public health is about, it’s what we do collectively, and it’s very, very political. What we do in public health is extremely political. The politics of policy making, the politics of program development, absolutely, the big ‘P’ politics of resource allocation, really means that you’ve got to engage, folks, in this process early, and often. You’ve got to involve your stakeholders, the people who have interest in what it is you’re doing, because what you’re doing means change. Do this right and you’re going to change things. It’s a lot easier for you if you do this early, if you get people involved early, let them get their hands dirty right along with you, let them struggle through these decisions with you, and have them be with you at the end, than for you to do this work on your own, and then spring it on them later. We’ve all been there and it’s not a pretty place to be!
Needs assessments help you do a couple of things that are really important in MCH. They help you bridge this scientific knowledge base, the data, with the politics. Politics aren’t data driven. They are emotion driven they are vote driven, right, ok? But that’s the reality we live in, we can’t deny that that’s the reality, we can’t pretend that it’s going to go away because it’s not. A good needs assessment process helps you bridge those two worlds. It helps you bring the data, the quantitative scientific data, to the values of the community. People have their own ideas about what is going on in their communities. They don’t care what your data says. So, we need to bring those two things together. And, as I’ve said before, I’m going to say it again, it helps to bring the needs together with some strategies and some approaches for their solution. It’s not enough to identify the need. You’ve got to have the solution that goes along with it, and a good process will help you do that, and in the doing, will help you sort out what’s realistic, what’s manageable, what’s going to be worth your investment of time and energy and resources. People will present to you needs that you have no prayer of dealing with, and if they’re with you in that process, hopefully that can sort itself out.
Now, we know that we’re required by law, every 5 years, to conduct comprehensive needs assessment. This isn’t news, but the fact of the matter is, that isn’t enough. We really need to embrace this as an ongoing process. We have to be doing it all the time. In fact, you are doing it all the time. You might not identify it that way, but you are doing this all the time. What the 5 year needs assessment, to me, really is or allows you to do, shouldn’t be viewed as a chore, it should be viewed as a point at which you come back and revisit what you’ve been doing, you formalize the process, and you think about how to, perhaps, change the way you do current and future planning. It’s just a point in time. If you’re doing this all along as an ongoing process, part of your normal planning, the 5 year assessment allows you to step back and say ‘alright, how have we been doing that, how’s it working?
Do we have the data we need? Have we involved the community the way we wish to? Where has it not helped us? How might we change what we do?’ It allows you to then to take a big picture approach to your 5 year plan understanding that in those 5 years things aren’t static, the world’s changing, you’re changing. A friend of mine always talks about planning, don’t forget that things are happening while you’re planning. It’s not like the world stands still while you plan and then we can say ‘ok, here’s my plan, now we can start up again’. Things are going on out there and you’ve got to be in tune to that. So the 5 year needs assessment really is a time that you can stand back, take a deep breath, invest some time and energy and say ‘how’s this process been working?’ while I’m trying to learn about what’s going on in my communities.
It also, and I think we forget this, part of the 5 year needs assessment should be part of the plan that comes out of the 5 year needs assessment should be a plan for other assessment activities within the 5 years. Does that make sense? So, that, one, you’re sort of revisiting the generic process, but you should also be saying, as a part of that, I really want to spend some time in the next couple of years focusing on a particular population group, a particular community, a particular health issue that I didn’t know enough about for this big needs assessment. That should be part of the plan. And, in fact, when we talk about solutions later, or performance measures, that might be a solution, if you will, at this point in time, I need to know more about this problem. It’s come up, I’ve heard it over and over again, but I don’t have enough data, I don’t know enough about it yet, and if I don’t know enough about it yet I don’t know what it is I need to do about it, right? So, thinking about what might I do in the intervening years.
Now, we should not do this just because we have to. We have to get over that. And we definitely shouldn’t do it to justify what we already do. Don’t bother. And we shouldn’t do it if we don’t intend to act on the results. We really need to understand going in what we’re getting into here and embrace that and take it on move ahead. I’m doing this because it’s the right thing to do, I understand the dynamic nature of maternal and child health. I gave a lecture to some students yesterday who work at our children’s hospital across the street and I told them a story years ago, I have blocked out this man’s name, purposely, he was the administrator at HRSA at the time, we were at a meeting and he said ‘You know, you’ve been doing this MCH stuff for 45 years, aren’t you done?’ Aren’t you done? Haven’t you done it all? And they immediately jumped up and said, because they’re right here in Children’s Hospital, they’re in the neonatology unit, they know, we’re never done. We are never done. And we have to always, and nor do we know everything, so we understand the dynamic nature of this population. We understand that the world changes. We’ve got to. We’ve got to invest in these kinds of activities.
We do want to be good stewards of the public’s trust. We are public servants after all, and we understand that public health is what we do with our communities and we want to do that well. And we know, unfortunately, that we have to set priorities, we have to make tough decisions within limited, and I think for all of us, shrinking resources. I think I read somewhere that only Wyoming wasn’t in debt. Is that correct? Every other state, so I don’t know, I tried to move to Wyoming, Vermont is not in debt, well, hurrah. The comment was that Vermont is not in debt thanks to a governor whose name we might recognize, and I saw in the paper that that man is now going to show us who he really is. Is that a good thing? Do we really want to know who he really is? Do we not know who he is? It’s been twisted. OK. Things are twisted out there. So only Vermont then has the luxury then of perhaps not facing this harsh fiscal reality the rest of us are facing, but we don’t have the resources we used to have.
And not only do you not have the dollars, I always enjoy going out and meeting folks because I hear these stories, and you wish you didn’t have to hear these anymore, about hiring freezes, and riffs, and so you couldn’t fill the position and then suddenly you get somebody from another agency who knows nothing about what you’re doing, and it’s all about, these things, it’s just endless. The challenges that you have to face. Having processes like these probably sound counter intuitive, but they can be helpful to you, these things can be helpful to you. When we talk about needs assessments, we can be talking about a whole host of different things, and we need to be thinking about what are the parameters of this assessment that I’m conducting, or that I’m thinking of conducting. Is it statewide? For this one it is. It has to be. But it doesn’t only have to be that. Even for the 5 year needs assessment you might do some focused activities within certain communities, or as I said, in the intervening years, you might learn from your, what I’ll call the maybe broader and not as deep assessment at the state level that there’s something going on over here, whether it’s the eastern shore of Maryland or the mountains of West Virginia or something in the tri-state area that you want to focus on.
You know, maybe a deeper assessment. Are you talking the entire population or are you talking a particular population groups? Again, for this needs assessment we’re talking everybody, all children, all mothers, all babies, all women, however you define it. But again, you might note, that maybe adolescents deserve some special look, there’s something going on there that we want to understand. Maybe we had new immigrant populations that we don’t know enough about, that our data systems don’t keep up necessarily. I know, I’m, I’m down in Birmingham now, and we did not have a large Hispanic population, we didn’t really have one at all, and you know, I’m not paying much attention to this stuff, but I go to my little Piggly Wiggly, anybody have Piggly Wigglies? And out of nowhere one day, my little Piggly Wiggly, and this is little, little community, there is like half an aisle of hot peppers, tomatillos, cactus, different mole sauces, things I’ve never seen before. Well, something is going on in this community, because the Piggly Wiggly, you know, they’re responding to the needs of the community.
Then you start looking and seeing Spanish language church services, signs. You start noticing this. The data doesn’t tell you that, right? The data is always a little bit behind, but you are in tune to these things going on in your communities. You’re assessing this stuff all the time. All of MCH or just certain parts of MCH? Do we need to really focus on children with special health care needs? Is that an area that really needs some better understanding, some reinvigorating? Are we looking at every single issue or are we focusing on a few key topics? What might be the concern, we have a lot of folks from genetic services, is that an issue we really want to focus on? Maybe. And is this something we’re really doing on our own, directing this on our own, or are we doing this in collaboration with other groups, because you know this, you aren’t the only one doing needs assessments. Right? Lots of people are out there doing this. Primary care folks might be doing this, your early childhood might be doing this, March of Dimes is out there doing needs assessment, right? So you want to know about that so you can, you know, capitalize on those operatives. They’re out there gathering some information. One, you’d like them to do it in a way that’s helpful to you, but you’d like to bring that into the fold so that we can really extend our efforts in needs assessments.
You want to think about those things. Then, as I said, you may find that you want to undertake some focus needs assessment intervening years. I’ve given you some examples I’ve already alluding to, it might be that you want to focus on the needs of youth in your community, maybe incarcerated youth are an issue in your state. Maybe you’re noticing more farm related injuries that you want to focus on, what’s going on there? Maybe you want to look at recent immigrant populations, frontier counties. I don’t think we have those in these regions but we certainly do out west. Maybe there are specific urban areas that we want to target, right? So you want to be thinking about that. You can’t do everything in this 5-year Needs Assessment, it’s not possible. What you want to do in this 5 year needs assessment, as I’ve said, is kind of stop and see where you are, revisit the process you’ve been using, take this broad look, but then you also want to be saying ‘where do I need to focus my assessment energies into the future’, because you can’t do it all.