Beginning with the End in Mind: Supporting the Development of Health Improvement Plans Designed for Action

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• Beginning with the End in Mind Supporting the
  Development of Health Improvement Plans Designed
  for Action

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Learning Objectives

• Participants will
• Know important elements of an actionable CHIP
  that also enables ongoing monitoring and
  evaluation.
• Be able to describe techniques for engaging
  partners in a participatory action planning
  process.
• Know the major phases of implementation and ways
  to set a group up for successfully moving from
  planning to action.

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Priorities have been selected based on having a
picture of what is
Refer to the data related to Priority Issue.
In some cases, more work on understanding the
problem may be necessary.
Illinois Public Heath Institute
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Action planning to address priorities begins with
the end in mind
Current Status of the Priority Issue
What changes need to occur to achieve Vision?
Vision for the Future with Improvements Related
to the Priority Issue
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Facilitating Action Planning

• Beginning with the End in Mind

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Peer Sharing Experiences with Action Planning
Implementation

• What is your experience with community health
  improvement action planning and implementation?
• Thinking about one such experience
• How would you describe the action planning
  process in one word?
• What went well? What were the challenges?
• How did you/they get the ball rolling with
  implementation?
• Where did the implementation process get stuck?
• What should have been done differently?

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Participatory Methods for Action Planning
Rather than trying to explain or teach what is
needed, the facilitator attends to the process of
change. To facilitate is to elicit, sustain, and
enhance change. To facilitate is to let go of
controlling others toward predefined results and
to help them accomplish what they want. -Jim
Rough Dynamic of Facilitation
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Facilitating Action Planning

• Participatory Action Planning
• Brings diverse experiences and ideas into the
  process
• Helps ensure buy-in for implementation
• Brings key stakeholders to the table avoids the
  norm, If you arent at the table, you are on the
  menu
• Is more successful when guided by a skilled
  facilitator

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Organization Infrastructure

• Organizing the Process
• Identify up front what is known about resources
  and budgets available for creating and
  implementing the CHIP
• Timeline
• Schedule
• Human resources
• Review and feedback loops
• Finalization and adoption decisions
• Documentation of the process

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Organization Infrastructure

• Organizing Human Resources
• Engage a Steering committee (advisory group or
  coordinating council) in laying the foundation
  for the action plans
• Connected to all parts of the community
• Balance of thinkers, do-ers, and
  decision-makers
• Engage action planning teams/workgroups in
  building the action plans
• Ensure that those who are responsible for acting
  on the plan are involved in its creation
• Identify a lead or chairperson and other
  important roles
• Every group needs a mover and shaker

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Consulting on Key Elements of the CHIP

• A high quality CHIP includes
• What, how, who, when are clearly delineated
• Actions target multiple levels of the
  Socio-ecological Model
• SMART objectives for each strategic priority
• Alignment with Healthy People 2020
• Evidence-based health improvement strategies
• Monitoring and evaluation activities, measures,
  timeline

• PHAB requires
• Objectives
• Time-framed targets for strategies
• Evidence-based strategies
• Policy changes needed to accomplish objectives
• Accountable parties for each objective

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Levels of Objectives Measurable Outcomes
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Organization Infrastructure
Organizing the CHIP Structure A Basic Model
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What can be done to create the necessary changes?

• Important questions to answer before writing the
  action plan
• What are the existing resources, assets and
  strengths for this work?
• Who is already engaged in this work? What are
  they doing to address this issue? Can we
  partner?
• Who else needs to be engaged in this work?
• What are the barriers? How can the barriers be
  overcome?
• What has worked elsewhere (other communities,
  states etc.)?
• What are the evidence-based approaches to create
  the change we seek?

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Example Action Planning Worksheet
Sample from IPHI
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Participatory Methods for Analysis

• Facilitating Participatory Analysis of Issues
• Root cause analysis Why do these issues really
  exist? What is at the root of this issue? What
  should we really focus on?
• Underlying contradictions (barriers and blocks)
  What may block us from addressing our strategic
  issues and moving toward our vision?
• Stakeholder analysis Who will be affected by our
  strategies and how can they be engaged?
• Environmental scan What currently exists in our
  community that may influence the success of our
  strategies?

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Participatory Methods for Analysis

• Root Cause Analysis
• Social Determinants Tree
• The Five Whys
• Health Problem Analysis worksheet
• Role of the facilitator
• Help the group gain a deeper understanding of the
  issues
• Walk the group step-by-step through a process
  that links the identified issue to the root
  problem by asking why and how
• Infuse social determinants of health and health
  equity into the conversation

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Participatory Methods for Analysis

• Underlying Contradictions
• Unquestioned assumptions, mindsets, beliefs, and
  practices that oppose the vision.
• Not a lack of, but rather a log jam or kink in
  the hose
• Images and attitudes, structures and patterns out
  of which people operate
• Role of the facilitator
• Create space for dialogue about clusters of
  barriers and underlying themes
• Help the group recognize productive avenues for
  action that respond to, impact, or go around

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Participatory Methods for Analysis Underlying
Contradictions

• Focus Question What is blocking us from moving
  toward our vision?
• NO DISCUSSION OF LACK OF
• Focus on one element of the vision individual
  brainstorm obstacles (external policies, patterns
  or structures, internal images, perceptions or
  attitudes)
• Share brainstorm with small groups, develop one
  list for small group
• Bring ideas back to the large group, develop
  large group list
• Form clusters of ideas, name the clusters
• Review results and discuss
• What stands out about our obstacles?
• What is the importance of each cluster?
• What is the underlying contradiction (the block)?
• Discuss actions that could deal with each cluster
  of contradictions
• Prioritize the actions to address the
  contradictions

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Participatory Methods for Analysis

• Stakeholder Analysis
• Identify and develop key relationships for
  successful implementation
• Circles of Engagement
• Role of the facilitator
• Help the group understand each circle and
  identify stakeholders within each
• Create a picture of the current situation, the
  ideal situation, and identify gaps

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Participatory Methods for Analysis

• Environmental Scan
• Gain insight into community contextual factors
  related to the priority area, and that may drive
  or influence the implementation of the action
  plan.
• ToP Wall of Wonder
• Role of the facilitator
• Create space for dialogue that clearly describes
  present and future assets, challenges, benefits,
  and dangers
• Discuss plans for present and future trends,
  factors and events
• Help identify synergistic linkages to and gaps
  in existing efforts

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Participatory Methods for AnalysisToP Wall of
Wonder
Level of influence Past Present Future (foreseeable) Trends
Federal Economic Political/Policy Social Cultural Environmental Technology Factors Events Factors Events Themes that play out over time
State Factors Events Factors Events Factors Events Themes that play out over time
Local Factors Events Factors Events Factors Events Themes that play out over time
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Example Action Planning Worksheet
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Example Action Plan Template
Sample from Wisconsin Association of Local Health
Departments and Boards
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Goal/Outcome
Example Action Plan Template

Objective
Strategies/Action Steps Partners/Persons Responsible Timeline Outcome Indicators

Monitoring/Evaluation Approach
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Desired Outcome (product)
Example Sustainability Planning Template

Desired Outcome (product)
Strategies/Action Steps Partner/Person Responsible Timeline Outcome Indicators Monitoring/Evaluation Approach

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Sample from MPHI
Example Action Plan Template
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Facilitating Implementation

• Beginning with the End in Mind

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Participatory Methods for Implementation

• Creativity is thinking up new things. Innovation
  is doing new things A powerful new idea can kick
  around unused for years, not because its merits
  are not recognized, but because nobody has
  assumed responsibility for converting it from
  words into action. Ideas are useless unless used.
  The proof of their value is only in their
  implementation.
• -Theodore Levitt

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Transitioning from Action Planning to
Implementation

• How do you think of your action plan? If you
  think of your plan
• As a stack of paper you will use it to fill up a
  file.
• As a burden you will use it to remind yourself
  and others of overwork.
• As a carrot and stick you will use it only on
  others less committed than yourself.
• As a covert operation you will use it yourself
  and keep it from others.
• As a critical opportunity you will pour all your
  energy into it, and burn out and get grumpy
  before long.

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Transitioning from Action Planning to
Implementation

• If you think of your action plan as a roadmap for
  a momentous journey for your community, you will
• Move eagerly forward to each new step
• Participate in and appreciate both the ups and
  downs of the road
• Capture images of beautiful sights along the way
• Notice and welcome changes in yourself and others
  as you move toward your destination.

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Moving from Action Planning to Implementation

• Implementation is
• A shift in the whole system.
• Realizing the goals and milestones of the plan.
• Engaging people as change forces.
• Actively facilitating the whole journey to ensure
  intended results.
• Actively monitoring the whole journey to ensure
  learning and growth.

PHAB requires communities to implement elements
and strategies of the health improvement plan, in
partnership with others.
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Moving from Action Planning to Implementation

• The role of the facilitator during implementation
  is to
• Attend to the task, people, and process.
• Set-up processes that are participatory and
  responsive.
• Assess the situation on an ongoing basis, and
  facilitate processes to help the group retain or
  determine new focus.
• Engage stakeholders in consensus building.

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Moving from Action Planning to Implementation

• We are all much more likely to act our way
• into a new way of thinking
• than to think our way into a new way of acting.
• -R. Pascale, M. Millemann L. Gioja
• Changing the Way We Change

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Moving from Action Planning to Implementation
Four Phases of Implementation

• Getting started
• Building sustaining momentum
• Making adjustments
• Bringing closure

Institute of Cultural Affairs, Technology of
Participation (ToP) Four Dimensional Model of
the Implementation Journey
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Moving from Action Planning to Implementation Get
ting Started

• Elements of this Phase
• Need to integrate into operations and existing
  demands
• People work in unfamiliar ways turf issues and
  changing roles
• People feel excited, discouraged, challenged,
  anxious
• Implementation Dip
• Need for coordination of structures, roles, and
  patterns of interacting
• Need for high energy, rapid, visible quick wins

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Moving from Action Planning to Implementation Get
ting Started

• Keys to Success in this Phase
• Ensure the plan has potential for quick, highly
  visible results
• High energy, Kick-Off event
• Catalytic actions to smooth out challenges of
  working together
• Communicate the plan to all stakeholders
• Decide on a guidance group and process
• Set up a monitoring and communication system
  (process products)

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Moving from Action Planning to Implementation Bui
lding Sustaining Momentum

• Elements of this Phase
• Energy will ebb and flow, long term initiatives
  will tire people out
• Leadership and staff may be in flux
• The guidance group may struggle with how to hold
  themselves and others accountable
• Organizational development and refinement of
  systems and technologies is likely needed
• Support of individuals and building of capacities
  becomes critical
• Steady and reliable monitoring and communication
  is the lifeblood

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Moving from Action Planning to Implementation Bui
lding Sustaining Momentum

• Keys to Success in this Phase
• Celebrate small accomplishments
• Make public displays of progress
• Maintain regular, informal reports, feedback, and
  interchange
• Keep stakeholders in the communication loop
• Trainings for individual and team capacity
  building
• Develop new leadership, rotate roles
• Utilize unexpected leverage points

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Example Quarterly Action Plan Team Report
Title of Action Plan Team chairperson Quarter Project year
Accomplishments Date of Accomplishment
Blocks/difficulties Going well
Team recommendations for next quarter Team recommendations for next quarter
Planned actions next quarter Planned actions next quarter
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Example Solutions Workshop
1. Define the topic you are working on 1. Define the topic you are working on
2. Clarify the what and why of the topic 2. Clarify the what and why of the topic
3. Brainstorm Issues Facing Us Go around, each person lists an issue, and keep going until all issues are listed. 5. Brainstorm Possible Actions Go around, each person brainstorms a different action to consider to address the issues until all are listed.
4. Star 1-3 Key Issues to Focus On From the list, choose 1-3 key issues that you believe are the most relevant challenges 6. Choose 3-4 Actions You Will Do As a group, review the list of suggested actions, circle 3-4 actions that you will actually do.
7. Create and Image or Slogan to Solidify your Decision Draw a graphic image or write a short statement that explains and clarifies the actions you will take. 7. Create and Image or Slogan to Solidify your Decision Draw a graphic image or write a short statement that explains and clarifies the actions you will take.
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Moving from Action Planning to Implementation Mak
ing Adjustments

• Elements of this Phase
• Significant learning about what works and what
  does not work
• Deep struggle and new resolve
• Group capacity and camaraderie pays off
• Moving toward self-sustaining initiatives
• Deciding between a bump in the road and hitting a
  wall
• Failures become revised strategies
• People will need help in being honest about
  reporting what did not get done

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Moving from Action Planning to Implementation Mak
ing Adjustments

• Keys to Success in this Phase
• Prepare for low points and high points
• Develop short range action plans when you get
  stuck
• Be prepared to change directions when your plans
  are no longer appropriate
• Strengthen facilitation skills of the group
• Reframe failures
• Use a visual monitoring form (both on display and
  on paper)
• Hold milestone meetings to mark turning points
  and plan to move ahead

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Example Re-Maneuvering Planning Session

• Re-Maneuvering Planning Session
• Bring back together the action planning
  team/workgroup
• Review the vision, results of data gathering, and
  strategic priorities that lead to this strategy
  and action plan
• Discuss what still seems on target and what is
  off
• Brainstorm
• What has been accomplished?
• What accomplishments have really moved us
  forward?
• What blocks are we hitting?
• What is needed right now to get on track?
• Develop a 90-day action plan that coordinates
  with existing plans

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Example 90 Day Action Plan
Strategic direction Strategic direction Strategic direction Strategy Title (what) Strategy Title (what)
Intent (why) Intent (why) Intent (why) Start date End date
Action Steps Action Steps Who When Where
1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4.
Coordinator Collaborators Evaluation Budget Progress Update
Team members Collaborators Evaluation Budget Progress Update
Team members Collaborators Evaluation Budget Next Meeting
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Example Quarterly Meetings
Quarterly Planning and Evaluation Meeting Schedule Quarterly Planning and Evaluation Meeting Schedule Quarterly Planning and Evaluation Meeting Schedule Quarterly Planning and Evaluation Meeting Schedule
Participants Those involved in planning and implementation Rational Objective Assess accomplishments, recognize successes, and plan for next period Experiential Objective Affirm and re-energize individuals and the team Product/Outcome Clear tasks and roles for the next period Report on progress to the steering committee
Qtr 1 Qtr 2 Qtr 3 Qtr 4
Qtrly Planning and Monitoring Qtrly Planning and Monitoring Qtrly Planning and Monitoring Annual Planning and Evaluation
Review of vision, objectives, and strategies Evaluation of 90 day action plan (accomplishments, activities completed, blocks, learnings Plan for next 90 days (measurable outcomes on qtrly timeline, review action plan Review of vision, objectives, and strategies Evaluation of 90 day action plan (accomplishments, activities completed, blocks, learnings Plan for next 90 days (measurable outcomes on qtrly timeline, review action plan Review of vision, objectives, and strategies Evaluation of 90 day action plan (accomplishments, activities completed, blocks, learnings Plan for next 90 days (measurable outcomes on qtrly timeline, review action plan Review vision, objectives, and strategies Evaluation of annual action plan (accomplishments, milestones, outstanding activities, blocks, learnings) Develop measurable outcomes for next 12 months on qtrly timeline Create detailed 90 day action plan
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Moving from Action Planning to Implementation Bri
nging Closure

• Elements of this phase
• Peer recognition of accomplishment begins to
  emerge
• Reaching out to other similar efforts
• Unanticipated outcomes, challenges, and
  consequences
• The new reality emerges
• Victory needs to be celebrated and contributions
  affirmed and appreciated
• The change effort needs to be recognized for its
  larger significance

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Moving from Action Planning to Implementation Bri
nging Closure

• Keys to Success in this Phase
• Write a powerful story of what happened
• Build in unmistakable closure on tasks with an
  end date
• Hold a highly visible celebration
• Recognize and appreciate commitment and
  contributions
• Articulate the learnings that occurred
• Assess and propose improvements to the overall
  process used

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Example Implementation

• Oklahoma Health Improvement Planning
• http//www.ok.gov/health/Organization/Board_of_Hea
  lth/Oklahoma_Health_Improvement_Planning_Team_(OHI
  P)_/OHIP_Work_Group_Quarterly_Reports/index.html

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Peer Sharing Challenges Resolutions

• Within your small group
• 1) Answer these questions
• What is one experience you have with action
  planning and/or implementation?
• What was one challenge you faced?
• What would you do differently next time to
  resolve the challenge?
• 2) Everyone shares and records
• 1 Give-Away Something (resource, tool, tip) I
  know or use that could be helpful to others
• 1 Take-Away Something I learned that I will take
  back with me and explore further

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Peer Sharing Large Group

• The reporter for each group will
• Summarize your groups experiences
• Highlight 2-3 gems of the discussion
• Lesson learned to resolve a key challenge
• Challenge to explore further
• 1 Giveaway 1 Takeaway that could benefit the
  large group

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Wrap-up

• Key Points
• Action planning is both process and product.
• There are key issues to attend to in each of the
  phases of the implementation cycle.
• Facilitation is a key role in successful action
  planning and implementation.

• The bottom line of systems thinking is
  leverage- seeing where actions and changes in
  structures can lead to significant, enduring
  improvements. Often, leverage follows the
  principles of economy of means the best results
  come not from large-scale efforts but from small,
  well-focused actions.
• -Peter Senge

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Resources

• When to Apply QI Tools to Support Measurement
  Activities, Public Health Foundation and National
  Network of Public Health Institutes, 2013.
  http//www.phf.org/resourcestools/Documents/QI20T
  ools20and20Measurement20Activities.pdf
• New CHIPP Resources (Website). Wisconsin
  Association of Local Health Departments and
  Boards. http//www.walhdab.org/NewCHIPPResources.h
  tm
• The Community Guide. http//www.thecommunityguide.
  org/index.html
• NACCHO Model Practices Database.
• Choosing Effective Policies and Programs. County
  Health Rankings Roadmaps.
• Healthy People 2020. http//www.healthypeople.gov/
  2020
• Guide to Clinical Preventive Services
  http//www.ahrq.gov/clinic/pocketgd.htm
• National Resource for Evidence Based Programs and
  Practices www.nrepp.samhsa.gov
• Technology of Participation. Institute of
  Cultural Affairs

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Contact Information
Shannon Laing, MSW Center for Healthy
Communities Michigan Public Heath
Institute slaing_at_mphi.org 517-324-7344