THE 2017 CHIP PROCESS

The CHIP process includes five phases: 1) planning; 2) recruitment; 3) development; 4) implementation; 5) monitoring and evaluation. Each phase is described below in Figure 3.

PHASE 1: THE PLANNING PHASE

The Health Collaborative and Metro Health started planning the 2017 CHIP in August 2016 after the release of the Community Health Needs Assessment (CHNA). Selected members of The Health Collaborative board serving as a data committee, staff at Metro Health and staff at the Health Collaborative formed the CHIP Steering Committee to plan and guide the 2017 CHIP process. The CHIP Steering Committee’s first step was to compile information from several recent local and national and relevant community plans to understand their health priorities, goals, and indicators. As presented in Appendix A, the plans included:

Healthy People 2020
Centers for Disease Control and Prevention’s Winnable Battles
SA 2020 Plan
2015 SA Tomorrow Comprehensive Plan
2017-2019 City of San Antonio Metropolitan Health District Proposed Strategic Plan
2014 City of San Antonio Community Survey
2016 Bexar County CHNA
2014 Bexar County CHIP
2013 Austin/Travis County CHIP
2013 Houston CHIP
2013 El Paso County Community Health Assessment and Improvement Plan

This overview of plans and outcomes provided a realistic comparison of how different entities were proposing to address and measure important health priorities affecting our communities. Over the course of several meetings, the CHIP Steering Committee discussed these plans, brainstormed potential headline indicators to recommend to the workgroups for the 2017 CHIP, and made the determination to maintain the same five CHIP priority areas as selected in 2014. The final five CHIP priority areas are:

Behavioral and Mental Well-Being
Healthy Child and Family Development
Healthy Eating and Active Living
Safe Communities
Sexual Health

Through this examination, the CHIP Steering Committee also noticed the emergence of several larger social concerns that were transcending across the potential indicators, such as poverty and education. This is how the four overall themes of the CHIP process were determined. (See Overarching themes within the CHIP process on page 18.)

During the planning phase, it was determined that the 2017 CHIP would be guided by selected features of the Results Based Accountability (RBA) framework. RBA is a “disciplined way of thinking and acting to improve entrenched and complex social problems” (Clear Impact, 2017). It uses a “data-driven, decision-making process to help communities and organizations get beyond talking about problems to taking actions to solve problems” (Clear Impact, 2017). It is effective by keeping the end in mind and working backwards toward the means and strategies needed to achieve this goal. Only a few headline indicators are selected and targeted for improvement in order to maximize the community’s efforts and to ensure that the partners involved in the process become accountable for progress made to achieve the expected goal. Metro Health recently used the RBA process to develop its strategic plan for 2017-2019. Several of their staff were well versed in the RBA process already and served as lead facilitators for the five workgroups. A glossary of RBA terms can be found in Appendix B.

The last step of the CHIP planning included identifying people to participate in the development of the CHIP; thus, local collaborations and organizations that were already working in the community on the final five priority areas were identified. In addition, lists of previous CHNA and CHIP attendees were compiled to ensure a broad representation across sectors and types of organizations.

PHASE 2: THE RECRUITMENT PHASE

CHIP workgroup participants were recruited between December and early February via email using a joint letter from Metro Health and The Health Collaborative. Compiled lists of prior CHNA and CHIP participants were utilized to recruit participants as well as word of mouth at various coalitions, taskforces, and community meetings. Participants committed to their preferred CHIP workgroup via email or telephone. The CHIP Steering Committee also took steps to ensure that the same people came to all five workgroup meetings, and if a proxy was sent, that it was for a limited number of meetings. Also knowing that strategies and actions would be requested at the end of the development phase, organizational leaders and decision makers were recruited to participate or send a delegate to participate on their behalf.

PHASE 3: THE DEVELOPMENT PHASE

Metro Health and The Health Collaborative organized a total of five meetings from March to July 2017 to develop the CHIP. The process was guided by selected features of the RBA process illustrated in Figure 3.As Metro Health had recently employed the RBA process for their strategic plan, their staff took the lead in conducting this phase and training the workgroup facilitators. Prior to each CHIP workgroup meeting, the workgroup facilitators (ten Metro Health staff members and five Health Collaborative staff members) and workgroup advisors (five Metro Health staff members) received training on meeting facilitation, the RBA process and methods related to the upcoming meeting. Several tools were used by the facilitators and their workgroup to assist with group decision making. For each step in the CHIP development (e.g., selecting a headline indicator), the workgroups used one or more matrices to rank the potential options being discussed using a list of criteria (e.g., data power, proxy power, communication power, impact on life expectancy likely, significant impact on population health). This helped the workgroups make the best collective decision possible. A guide that includes most of the matrices used in the CHIP process is available in Appendix C.

Specific objectives were set for each CHIP meeting:

Meeting 1 was dedicated to drafting the results statement and selecting a headline indicator. This was no easy task because each workgroup had to choose from a broad range of important health issues in each priority area.
Meeting 2 was dedicated to identifying the prioritized root causesof each selected headline indicators and writing the story behind the baseline, i.e., the story that describes the current status of the health indicator in Bexar County. At the start of every meeting, each workgroup also had the opportunity to review what all the other workgroups had been working on and provide feedback. This was very useful for each individual workgroup to refine their own work, as well as for all participants to be able to compare and remain consistent with the overarching themes, while avoiding duplication of efforts.
Meeting 3 was focused on creating a list of potential partners and their roles and discussing potential strategies to address the root causes. During this meeting, a Health Collaborative graduate intern presented the results of her research comparing all 2014 CHIP strategies to existing population health evidence-based policies and programs from the University of Wisconsin Population Health Institute’s What Works for Health tool, as well as the Centers for Disease Control and Prevention’s (CDC) HI-5 and 6|18 website. She rated the 2014 CHIP strategies based on whether they had evidence (i.e., scientifically supported, some evidence, expert opinion, insufficient evidence, mixed evidence, evidence of ineffectiveness) and on their likely impact on health disparities (i.e., likely to decrease health disparities, no impact on health disparities likely, and likely to increase disparities).
Meeting 4 was used to finalize the strategies and to start thinking about specific collective performance measures and actions that different organizations could take to achieve each selected strategy.
Meeting 5 was dedicated to finalizing specific actions to be taken by each participating agency over the next three years.The action plan can be found in Appendix D.It is included separately because we expect this document to be frequently updated. Meeting 5 was also focused on planning the targets for each headline indicator that will result in positive health improvements in the community. In other words, if all of these actions and strategies are implemented to address the three or four prioritized root causes that drive the selected headline indicator, how much of an impact can we expect? How much can we turn the curve in favor of population health? Based on a review of the data, each workgroup discussed current efforts and forecasted where the trend line would go over the next three years without additional interventions. The workgroups also discussed how their selected strategies and actions would impact the trend line.

Workgroup members were in contact between meetings via email or survey monkey to complete their assigned homework and ensure that all the groups followed the planned timeline for these meetings. The CHIP steering committee also met monthly in between the CHIP meetings to receive an update on the progress of each workgroup and to provide data expertise as requested. For example, when selecting headline indicators, workgroup members needed to think about routinely available data sources at the county level that would allow the monitoring of changes in these indicators at the population level over time. Based on recommendations from the CHIP steering committee, a few workgroups changed some of their selected indicators to associated indicators instead to facilitate measurement of their headline indicators.

The community’s voice was also present during the entire CHIP development process. Similar to community partners, members of the community were invited to attend the CHIP meetings and participate in their preferred workgroup. In addition, ten community engagement opportunities were organized across the county to collect feedback from the community and act as a sounding board for the ideas and progress of the workgroups. See Figure 5 for location of community engagement efforts. See Appendix E for examples of qualitative data collected across the county.

Data from community members were collected using dot-voting, paper and online surveys. A total of 310 individuals residing in most of the zip codes in Bexar County provided invaluable input and ideas in both English and Spanish about what is important for good health, which CHIP priority is the most important, and the best ways to address the most pressing health issues in our community. Data collected through the community engagement opportunities helped to inform subsequent decisions made by both the CHIP Steering Committee and the five workgroups. The 10 events and the number of participants per event are described in Table 2.

PHASE 4: THE IMPLEMENTATION PHASE

The official community release of the CHIP in October 2017 will launch the implementation phase of this plan. A list of current community liaisons, implementing partners and engagement champions for each workgroup can be found in Appendix F. Community liaisons are volunteers from each workgroup who will help lead this process for a one-year term each. They will help keep the workgroups organized, chair the quarterly meetings, and ensure that there is progress toward accomplishing the workgroup’s action plans.

Implementation partners in each workgroup are organizations from each workgroup who have a vested interest in the proposed actions because of potential and existing alignment with organizational processes, plans, and programs. They also have the financial and/or human resources to make progress toward these goals and are able to report on the outcomes of their actions. As of the October 2017 launch, implementation partners will start implementing their proposed actions to address the root causes of their respective headline indicators.

Engagement champions will also provide support with community engagement efforts. Engagement champions help tap into the community’s voice through outreach and community awareness events. These partners plan conferences, community meetings, and different types of activities where residents gather.

The Health Collaborative will be in communication with the workgroup members and the implementation partners throughout the year to monitor implementation and to receive quarterly progress reports and updates (i.e., in January, April, July, and October). Progress completed in the first year of implementation will be reported on and shared at the annual CHIP meeting in October or November 2018.

Community members and partners interested in becoming community liaisons, implementation partners, or engagement champions can contact the Health Collaborative at 210-481-2573 or by email at info@healthcollaborative.net. Leaders are still needed for the proposed actions. All are therefore welcome to join and help the successful implementation of the CHIP.

PHASE 5: THE MONITORING AND EVALUATION PHASE

The implementation of the CHIP occurs simultaneously with the monitoring and evaluation of the CHIP. Three types of monitoring will be conducted:

Implementation monitoring consists of tracking the progress within each workgroup to ensure that the strategies and action plans from the CHIP are being implemented by community partners.
Community monitoring will be used to get feedback from community members during the implementation phase. Different events and meetings will be organized throughout the year by the engagement champions. The Health Collaborative will be invited at these meetings to gather community feedback on the CHIP actions and strategies being implemented.
Data monitoring will consist of tracking local data to ensure the activities to be implemented are helping to move the trend line of each headline indicator in the direction of the targeted goal.

Rapid adjustments to the strategies and action plans may be made if monitoring shows counter-effective community solutions. The CHIP represents a “living” or evergreen document. All revisions to the CHIP will be marked in Appendix G.

During the monitoring and evaluation phase, Metro Health and The Health Collaborative will collaborate with CI: Now to develop the data dashboard. This online tool will enable the visualization of progress made in each headline indicator over time. The full evaluation of the CHIP headline indicators and associated indicators will be conducted in 2019 for the next CHNA.