Phase V: Steps toward conducting a prioritization process

During this phase you'll determine the top issues for consideration, identify whether strategies are available to address the issues, identify stakeholders to engage, then plan and conduct the prioritization process.
Step 1: Use assessment results to identify five to 10 issues for consideration
For this step, you'll need to identify a manageable number of issues to consider during the formal prioritization process. The more formal prioritization process should narrow the priorities to no more than five focus areas. It's likely that during both the capacity assessment and community health assessment processes key issues began “rising to the top,” given their importance to community health, level of community need or window of opportunity to address. By prioritization time, it will probably be obvious which several issues should be included. If not, the project management team can further review the analysis from the assessments in terms of issue selection for prioritization. 
An alternate method for consideration is to have the steering committee select the top 10 issues at the same meeting where you present the results of the assessments. This would probably occur one meeting before the first prioritization meeting. A voting process is a good facilitation tool for this. One example is the dot process, in which each participant receives the same number of colored, adhesive dots. The number of dots received should be fewer than the number of issues being considered. The issues are first written on poster paper and posted in a common area. Participants then place their dots next to the issues they would like to examine more thoroughly through a prioritization process. The five to 10 issues receiving the most dots are then moved forward for further scoring and consideration at the prioritization meeting. 
Step 2: Identify potential strategies to address each issue
A strategy can best be defined as how a specific issue will be addressed. Examples include developing a new or enhanced:
  • Policy (e.g., seat belt law, tobacco control ordinance, land use regulation).
  • System-level change (e.g., after-hours health services, shared core public health services).
  • Service (e.g., restaurant inspections, family planning clinic, fluoride varnish clinics).
  • Infrastructure/capacity change (e.g., federally qualified health center, water system fluoridation, environmental health specialist position).
  • Program (e.g., emergency preparedness program, food handler training).
Understanding and choosing effective strategies is critical to the implementation of a local public health improvement plan. One reason that plans “sit on shelves” is that they were written without clear action steps using effective strategies or consideration of the resources needed to implement the strategies. Some strategies require significantly greater resources than anticipated. Some can also be ineffective, for example, using scare tactics to change behavior. The most impactful strategies positively alter health outcomes for a broad segment of the population. Most often, these create a long-lasting change to the environment or systems with which the community regularly interacts. The Health Impact Pyramid illustrates this relationship. 
Strategies that focus on lower levels of the pyramid tend to be more effective because they reach broader segments of the public and require less individual effort. Strategies that change a person’s environment so that the default behavior is the healthiest behavior have greater potential impact on public health. Smoking is one example of this. As smoking has been banned in many places (e.g., public buildings, workplaces, restaurants, bars) nonsmokers are exposed to significantly less secondhand smoke. This policy change significantly benefits public health.
During the prioritization process, your group should consider whether strategies are available to address an issue before deciding whether to make it a focus area. It’s likely that a community will have a health issue with great need but not a good strategy to address it. If this is the case, the issue might not become a focus area for public health improvement. This type of hard decision will help preserve resources for issues that are more actionable. This is why strategies need to be explored and vetted with stakeholders before the final priority areas are chosen.
There are several ways to research strategies. Begin by becoming familiar with strategies recommended by resources such as the Independent Task Force on Community Preventive Services’ Guide to Community Preventive Services, which recommends strategies based on level of evidence and degree of impact. Investigate recommendations made by initiatives such as:
Many Colorado Department of Public Health and Environment programs can assist in identifying evidenced-based strategies. Local public and environmental health experts in your area may also be able to offer valuable insights on strategy selection and implementation from practical experience. The Office of Planning, Partnerships and Improvement is available for technical assistance and can help connect you with content area experts who can partner with your team during the strategy identification and selection process.
Step 3: Develop a presentation summarizing each issue
Using the top five to 10 issues identified for the prioritization process, develop a presentation to share with stakeholders during the prioritization meeting(s). The purpose of the presentation is to provide enough information on each issue so that everyone in the priority setting process feels comfortable enough to score and rank it. For this reason, it will be important to provide an overview of the issues, including how each meets the scoring tool criteria listed below: 
Significance to community health
  • The prevalence of individuals affected or at risk (e.g., mortality, morbidity and injury rates).
  • The degree of health disparities or impact to subpopulations.

Ability to impact the issue
  • Existence of strategies/best practices likely to have an impact.
  • Level of community readiness and support for change (including political will).

Capacity to address the issue
  • Local organizations that are prepared to take the lead,
  • Sufficient resources, including staffing and funding, are available or obtainable.

It may work best to arrange your presentation in a manner that provides data, recommended strategies and other information by issue. Discussion after each issue is useful for criteria such as community readiness and capacity, which may not fit neatly to a presentation format. Providing a handout of the prioritization scoring tool along with the presentation will allow participants to take notes and write down preliminary scores as each issue is presented, so they can later refer back.
Step 4: Identify and engage stakeholders
If your group already has a steering committee that has been participating in the assessments, it would be the appropriate group for this process. Based on the issues identified for consideration the project management team should also determine who might be missing from the discussion. If you don't already have a steering committee formed, use the five to 10 issues to determine who in your community are in the following roles related to those areas:
  • Decision makers.
  • Potential funders.
  • Community organizations/other local public health agencies.
  • Community advocates and champions of an issue.
  • Public health and environmental health agency staff.
  • Other governmental directors.
Note: The prioritization process (including the scoring, ranking and discussion of issues) works best when conducted with stakeholders who have become familiar with the issues ahead of time, either through participation in the assessment phases or by exposure to the key assessment findings. If any participants are new to CHAPS, consider providing an orientation to give them the background information they'll need to make informed decisions during the prioritization process. 
Step 5: Plan the prioritization process

1. Facilitation
Determine who'll facilitate the meeting or meetings. The prioritization process will involve a considerable amount of discussion, both before issues are scored and ranked and afterward, to validate or change the rankings and to determine the number of priorities given levels of capacity. Using a trained facilitator will help guide the group toward gaining consensus and moving forward. The Office of Planning, Partnerships and Improvement can assist with identifying a facilitator.
2. Role of stakeholders in decision making 
Determine whether it's the role of the participants in the prioritization meeting to make the final decision on priorities for public health improvement or whether they're to make a recommendation to the Board of Health or other entity. Be sure to clearly communicate the participants’ roles and level of decision-making authority to the group ahead of time. Note that the public health agency need not be the lead organization on every community health priority. The more engaged stakeholders are in terms of being able to make decisions, the more likely that advocates and lead organizations will step forward.
3. Decision-making process
Determine how the group will make decisions during the prioritization meeting (consensus, majority, etc.). This step will be particularly important in the final discussion on which issues become focus areas and which do not. One consensus method to consider is using an informal show of thumbs or numbers in an electronic response system or “clicker” process. This technique lets the facilitator take the pulse of the group. For example: 
  • Thumbs up to show agreement or “2” in a clicker process.
  • Thumbs sideways to indicate “I can live with it” or “1” in a clicker process.
  • Thumbs down to show disagreement or “0” in a clicker process.
A process such as this will illustrate where there is disagreement and where there is common ground. This can also help to keep the group moving forward by allowing someone to indicate that he or she can live with a decision, even if it doesn’t represent his or her preferred outcome.
4. Scoring process
Standard criteria and a scoring mechanism are provided to support this step in the Prioritization Scoring Tool. The project management team will need to determine the type of process to be used. If your group is large, consider using an electronic response system. (The Office of Planning, Partnerships and Improvement can help to arrange this process). If the group is smaller, you may opt to have individuals fill out a score sheet to be tallied during a break, or the facilitator can ask for a show of hands and have a recorder tally the information.
5. Agenda
A thorough prioritization process will probably take three to four hours or longer, depending on the number of stakeholders and the number of issues. It may be structured as one or more meetings. If there are many participants and/or issues to consider, and a “clicker process” isn’t used, it may be necessary to have participants fill out their individual score sheets, turn them in for recording, and then come back for a second meeting.
Sample agenda: one to three meetings
  • Purpose of the meeting/background.
  • Set meeting norms (also known as ground rules).
  • Overview of decision-making roles and process.
  • Criteria for scoring.
  • Presentation/discussion on each issue (you may not get through all the issues in one meeting).
  • Scoring of each issue (it may work best to score after each issue has been presented and discussed, while it's still fresh in participants’ minds).
  • Facilitated discussion on rankings.
  • Choose focus areas.
  • Identify the next phase in the planning process.
It's helpful to send information, including the agenda and prioritization criteria, to stakeholders before the meeting for review.

Step 6: Facilitate meeting(s) to determine public health improvement plan focus areas
The initial part of the meeting should provide background in terms of purpose, the role of the group, the decision-making process and method of scoring. Consider setting ground rules or meeting norms, as well. Choosing priorities can be challenging, as decisions will be difficult and not everyone’s favorite issue will be selected. Ask the group to brainstorm norms for working together (e.g., confidentiality, respecting one another’s opinions, etc.) and record them on a flip chart that all participants can see during the meeting. Ask participants if they can agree to all of the norms. When a norm is broken, the facilitator can remind the group by referencing the flip chart.
The next part of the meeting will be the issue presentation. These are the five to 10 issues up for consideration to be focus areas for the public health improvement plan. The objective of this activity is to educate the participants about the issues, provide enough background so they can score them, and have a discussion so that participants can exchange thoughts and ask questions. This part of the meeting will take the longest; you may want to allow a half-hour to present and discuss each issue. It will work best if each issue is presented, then discussed, and probably even scored, before moving to the next issue. Use the criteria in the Prioritization Scoring Tool and have individuals score each issue. Add the scores together and then rank the issues in order of highest to lowest.
The final part of the meeting is selecting priorities based on the discussion of the rankings. Scoring and ranking is not a perfect process. As such, the group should discuss how the rankings came out. The facilitator can use questions such as the following to prompt discussion:
  • Is there a natural cutoff point for the highest-ranking issues?
  • Do these issues seem like they are ranked in the correct order?
  • Are there any criteria (like political will or lack of a lead agency) that may make a particular issue difficult to implement regardless of its score?
  • Of the highest-ranked issues, are there any that you think are not doable and if so, why?
  • Of the lowest ranked issues, are there any that you think are doable that we should reconsider?
  • Of the top issues, how many should be public health improvement priorities?
At this point in the process, the group should be close to consensus on all or most of the issues. A show of thumbs or use of the clicker can indicate consensus or disagreement. If there is disagreement among several members, either a discussion should continue or the group may decide they need more information before coming to a consensus or compromise. As decisions are made on focus area priorities, record them. Reflect any notes having to do with voting, dissenting opinion or any further actions needed before a consensus or compromise can occur.
End your meeting by discussing the next steps of the process. The priorities will need to be developed into action plans (explained in Phase VI). Consider what communication might need to occur with stakeholders who weren’t able to attend. Help the participants understand and/or determine their potential roles in future steps, and celebrate the completion of this milestone.