MCHB ALL GRANTEES MEETING

Role of the HRSA Field Office

October 4-7, 2004

JIM MACRAE: Thank you very much, Laura. When Laura initially asked me if I would be willing to come, she didn’t tell me exactly that it was going to be on a Sunday. So, I said, “Oh, of course, I’ll do this, it’s a Sunday.” Well, actually, I’m pleased to be here because for me, personally, the first weekend in October is a special occurrence in the McCray household. It’s the beginning of Halloween, I have a seven and an eight-year-old, and they are out of their minds about Halloween. And, my wife and I can hold them off for a while, but we always say the first weekend in October is when we’ll start decorating. So, yesterday morning about seven o’clock my son, a seven-year-old he comes into our room and I don’t really hear anything except for breathing next to me. And, so I sort of turn and he says, “Can we do the decorations now?” And, I said, “Well, all right,” and sort of woke up. So, we did a lot of decorations, but we didn’t quite get the outside done. So, this morning I thought okay, I’m prepared, he’s going to come in. Well, he comes in this morning again, very quietly, but this time he’s in his costume. And, his costume is a skeleton, which is green and white. The breathing is like, so I’m just glad to be here, so, anyway.

LAURA KAVANAUGH: You’re welcome.

JIM MACRAE: But seriously, what I like to do in about the next 10 to 15 minutes is just to give you a brief overview of what we are doing in the Office of Performance Review. As Laura mentioned like many other parts of the agency we have gone through a major transition in our work and our focus. And what I’d like to do is really talk to you about what it is that we see that we’re going to be doing and hopefully really adding value to both the work that you do, but also to our colleagues here at MCH, so that we can all do better in terms of improving people’s lives, both women and children, and really making a difference out there. In terms of our transition, I always make the joke about this slide is that after about two or three years we always have to change our name, and I think we’ve gotten really pretty good at it, but for us, I think the big change for when we became the Office of Performance Review, was really that transition of the project officer responsibilities. We had been project officers for a number of programs, including some maternal child health programs for a number of years, and I think we had some very good and positive working relationships with a number of you, I actually see a lot of folks that I recognize out in the audience.

But there was a decision made to centralize all that. And, I think the idea behind that was to really hopefully bring together the project officers at headquarters so that we could collectively be better in terms of the service and the assistance that we provided to you. But it was tough for our staff. I’m not going to lie about it, it was really a difficult transition. But the other side of the transition was what we were moving to, and to me, I think there’s some real value and hopefully some real positive things that we can do with respect to that. The biggest thing is that we’re not being asked to represent the agency in all its programs. So, in the past we worked with just a few, but now we really are going to have knowledge and hopefully some expertise in all of those programs so that they really can be a resource as you try to work with this overall HRSA entity that we are. In terms of our core functions there’s really four primary ones. The first, which I’m going to spend most of today talking about is the whole area of performance review. And, when we think about performance review we really think about it at three different levels.

The first is that a grantee or an organizational level, sort of the traditional review that you would do of a program of a grantee to really see how well you’re doing and what you could do to improve. The other types of reviews that we’re going to do though are a little bit more, I think, creative for parts of us, but not for everybody, but it’s to really look at a state level and then also at a community level about what’s the collective impact of a set of grantees, a set of programs within a community or within a state, and really hopefully working with you to figure out ways that we can better improve what we do from a policy and a design end, to really better support an overall collective effort, really in the communities and states where you live and breath. The second big piece for us is to really track what’s going on in the states and the regions. We’re out there, we’re in the 10 regional offices across the country, but I would say we have not done a very good job sharing back what’s really going on in states and in communities, and in regions.

And, one of the things that I always here is that, you know, you in Washington, you always have this one size fits all mentality, you really need to bring back what’s really going on in our state and in our region, and that’s one of the things we really hope to do in this new role. And, that really leads to the third big piece of our work, which is to provide real feedback from you about what are we doing that’s really working well? What are we doing in terms of policies, program designs? And, then what things can we do potentially to improve, to sort of deal with the real world that you all live in, and hopefully bring that back to us in the agency. And, then finally provide some level of technical assistance to help support you. In terms of our work itself, the performance review piece, when the administrator asked us to really focus on this, she put up this challenge which sort of on the surface seemed pretty straight forward, to develop an integrated grantee level review tool for use with HRSA grantees, focusing on the performance of HRSA funded programs.

Pretty simple on the surface, but when you start to tease that out it became definitely a little bit more of a challenge for us. The first thing that we were really asked to do was to develop an integrated grantee level review tool. So, instead of you being visited by multiple folks from HRSA, if you had grants from different programs within MCH or different programs from MCH Rural Health, Bureau of Primary Health Care, HIV AIDS, that instead of having multiple review teams, you just have one team come out. Actually, just to give me a sense, how many of you all out there actually have more than one grant from Maternal Child Health or HRSA from other programs, just to get a sense? Okay. So, about a third, that’s about what we’ve estimated. The second part of our challenge is really to develop a tool that focused and could be utilized across all the different programs. And, when you look at it as a collective whole, we’re about seven billion dollars going to about 3,000 different organizations, and about 80 different programs, definitely quite a mix.

And, then to further add to the complications of that, when you look at the range of different programs, you know, we support everything from community base to hospitals, to local government, state governments, associations, foundations, all the different folks who I assume are out in the audience today. In terms of then the last piece is really to focus on performance. And, this is really consistent with what’s going on in the greater government, what’s going on in industry, and I think most importantly, and I think really my colleagues and MCH have been the leaders, really where we as an agency want to go? Which is to really focus on the performance on the programs, and really be able to document what that impact is. In terms of the development of the protocol, we went through a lot of different iterations, we did some pilot tests, we got feedback and input, and we hope we’ve developed a really pretty straightforward tool, and to me that’s really the bottom line behind what it is that we’re trying to do. It’s to really help support you and help support us as an agency improve. And, in particular, it’s to go behind the numbers.

You can report on performance and that tells one part of the story, but what we hope to do through these reviews is to really dig deep and figure out what’s actually going on? What’s helping you actually create that performance, that good result? What may be potentially hindering you? So, that when we look at it collectively and nationally, we can also be able to tell your story of what’s going on, on the ground and in your communities and in your states. And, to me that’s sort of the real focus of this whole performance review. It’s really pretty straightforward, there’s three key pieces that we see. The first is to measure your performance against criteria that you all are already reporting on, either through your grant applications, through your Divis and Tigis and all those different reporting requirements that you all have at MCH. And, really then taking a look further to say what actually is causing that to happen, both on the good side, as well as on the negative side? And, even are there some HRSA policies that may be impacting or causing problems for you in terms of performing in your particular community or state.

And, then finally, working wit you to identify effective strategies and partnerships, which I really see as the theme of this meeting, to really help you achieve those results. Because when you talk about the outcomes and the results that, you know, when I looked at the Maternal Child Health, there is no way that one program, one grantee can achieve it by themselves, it really does take partnerships. And, I know you all are already doing that, but what we want to do is help support you in doing that, and also bring that back to our agency. In terms of the components, it really reflects those three major components, the first one, looking at performance review measures, then secondly doing an analysis, and then finally developing a report that identifies some options and best practices. And, then finally asking you what you can do or what you would like to do to improve. In terms of just some assumptions, I think it’s really important for us as we’re going into this work to be clear about what our assumptions are.

The first is that most of the organizations we’re visiting, most of the folks in this audience, you’re doing well. We’re not going in there, I think sometimes as we used to as project officers, looking for problems. We’re really looking at how you’re performing. The way I look at it is if you think about performance sort of on a bell curve, you’ve got some folks who are at one end of that tail who are doing extremely well, and what you want to do is really stay out of their way, but hopefully document some of those best practices and be able to share it, which I know a lot of our colleagues are doing internally, but hopefully, do that more systematically. Then on the other end of the tail you’ve got really, you know, some of the problems and some of the issues, but the vast majority are really folks in that middle category that are doing well, but maybe with some assistance, with some support, with hopefully looking at how things are actually performing, we can help you improve your performance. The second piece is to also look at performance first.

One of the things we’ve traditionally done is ask you to do certain things and by doing that we’ve assumed that the result would come, but I think what we’re really saying first is let’s look and see what is the result and then from that, how are you actually performing? What is it that’s causing that to happen? And, then finally the last piece is that we really do believe that a lot of the solutions exist within your organization itself. It’s not a question of additional resources, that’s always helpful, always needed and we will document that. But we really do believe that a lot of the solutions to potential programs and issues exist within your organization. Oh, and then finally we really see it working in collaboration with you. Let me race to the end because I know I’m getting the high sign, I think the most important piece for us in terms of the benefits is that we really see this being a focus on performance. And, really looking at, you know, beyond just sort of the numbers, but to really work with you to identify what’s happening. The second thing is that we hope this really is beneficial in that we’re looking at all the grants at one time, as opposed to doing sort of a scattered review over a period of time.

The third thing is that we really hope that by working with you we can identify some options. One of the things that we’ve really heard that’s been beneficial from these reviews as we’ve done our pilots and our initial ones, is that it’s really given you, as an organization, a time to take a step back from the day-to-day chaos that you all typically operate in and that we typically operate in to really focus on what’s most important, and then how can we together achieve that result that we all got into this business in the first place. And, then lastly, really the opportunity to provide feedback. And, we’re going to also be asking for feedback on our own performance. So, one of the things we built in to this whole system is actually the opportunity to get feedback from you once we’ve been out on site, and so we’re going to be doing surveys three weeks after we’ve been out there to really get a sense from you how well did we do, was this really beneficial? Did this add value to your operations? And, then six months later we’re going to ask again, and say did some of these actions, some of these options that we identified did you actually implement them, were they really useful. That’s a quick summary. I just wanted to also mention that Cindy Sego, Cindy if you could stand up, Cindy’s going to be available on Tuesday afternoon from 2:00 to 5:00 to provide more information.

We’ve got a bunch of handouts and then the last thing is I would encourage you all if you haven’t had a chance is to go on the HRSA website if you want more information about what our office does. There’s a lot of helpful resources there, our protocol, our sort of philosophy and practice of how to do it. It’s on the HRSA website and if you look under the spotlight section it says performance review. So, I really appreciate the opportunity today, and like I said, I’m going back to put lights on tonight, anyway, it’s very much appreciated to be here.