During this phase you will 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. A Phase V Work Plan template
that includes each of these steps
Step 1: Use assessment results to identify 5-10 issues for consideration
For this step, you will want to identify around 5-10 issues in order to have a manageable
number of issues to consider during the formal prioritization process. The more
formal prioritization process should reduce the priorities to 1-5 PHIP focus areas..
It is 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 5-10 or so 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 prior to 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 up 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 top 5-10 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., seatbelt law, tobacco control ordinance, land use regulation)
- System-level change (e.g., after-hours health services, shared core public health
- Service (e.g., restaurant inspections, family planning clinic, fluoride varnish
- 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 because they were not written with clear action steps using effective strategies
or without 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
Strategies that focus on lower levels of the pyramid tend to be more effective because
they reach broader segments of society 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) non-smokers are exposed to significantly less second-hand smoke.
This policy change significantly benefits public health.
During the prioritization process, your group should consider if there are strategies
available to address an issue before deciding whether to make it a focus area. It
is 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’ Community Guide to Preventive Services
, which recommends
strategies based on level of evidence and degree of impact. Investigate recommendations
made by initiatives such as National Prevention Council’s National Prevention Strategy
through the Office of the Surgeon
General; The Centers for Disease Control and Prevention’s Winnable Battles
Colorado’s Winnable Battles
; and the national Healthy People 2020
initiative. 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 and Partnership is available for technical assistance and can help link
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 5-10 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
Ability to Impact the Issue
- The prevalence of individuals affected or at risk (e.g., mortality, morbidity and
- The degree of health disparities or impact to subpopulations
Capacity to Address the Issue
- Existence of strategies/best practices likely to have an impact
- Level of community readiness and support for change (including political will)
- Local organizations that are prepared to take the lead
- Sufficient resources, including staffing and funding, is 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, they 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 do not already have a steering
committee formed, use the 5-10 issues to determine who in your community are in
the following roles related to those areas:
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 will
need to make informed decisions during the prioritization process.
Step 5: Plan the prioritization process
- 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
Step 6: Facilitate meeting(s) to determine public health improvement plan focus areas
Determine who will facilitate the meeting or meetings. The prioritization process
will involve a considerable amount of discussion, both before issues are scored
and ranked and afterward, in order 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 and Partnerships can assist with identifying a facilitator.
- Role of Stakeholders in Decision Making
Determine whether it is the role of the participants in the prioritization meeting
to make the final decision on priorities for public health improvement or whether
they are to make a recommendation to the Board of Health or other entity. Be sure
to clearly communicate the participants’ role 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.
- 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 utilizing 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 they can live with a decision, even if it does not represent
their preferred outcome.
- 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 and Partnerships 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.
A thorough prioritization process will probably take 3-4 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 sheet, turn them in for recording, and then come back for
a second meeting. A sample agenda is provided below.
Sample Agenda: 1-3 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
- Scoring of each issue (it may work best to score after each issue has been presented
and discussed, while it is still fresh in participants’ minds)
- Facilitated discussion on rankings
- Choose focus areas
- Identify the next phase in the planning process
It is helpful to send information, including the agenda and prioritization criteria,
to stakeholders prior to the meeting for review.
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
each other’s opinion, 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
The next part of the meeting will be the issue presentation. These are the 5-10
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 and you may want to allow a half an 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 cut off 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
- Of the lowest ranked issues, are there any that you think are doable that we should
- 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 either 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 were not able to be present. Help the participants to understand and/or determine
their potential role in future steps, and celebrate the completion of this milestone.