Adolescent Systems Capacity (ASC) Tool Helps Identify and Implement Organizational Improvements

By Sharron Crawford Corle, MS
Associate Director for MCH Leadership and Capacity Building, AMCHP

Maritza Valenzuela, MPH, CHES
Adolescent Health Program Manager, AMCHP

Laura S. Snebold, MPH
Senior Program Analyst, Maternal, Child, and Adolescent Health, NACCHO

State and local public health departments play an active role in ensuring the health and development of adolescents. In order to do this, maternal, child and adolescent health programs must have the organizational capacity to support adolescent health-focused efforts and improve coordination and integration of adolescent health services and programs. Modeled after Capacity Assessment for State Title V (CAST-5), the Adolescent Health System Capacity Assessment Tool (SCAT) was developed in 2005 as a resource to help state maternal and child health programs assess six key areas of organizational capacity related to adolescent health: commitment to adolescent health; partnerships for adolescent health; program planning and evaluation; surveillance and data systems; education and technical assistance; and policy and advocacy. The ultimate goal of the assessment is to identify areas for organizational improvement and implement strategies to address them.

Since 2005, a number of state health departments have used the SCAT to advance their adolescent health systems and programs. In 2011, recognizing the critical role that local public health plays in improving health outcomes, AMCHP initiated a project with the National Association of County and City Health Officials (NACCHO) to revise the SCAT to help local public health practitioners assess their organizational capacity to support adolescent health. The first phase of the project was to gather local public health input on the existing tool. To accomplish this, AMCHP and NACCHO brought together a group of local public health practitioners and their key adolescent health partners (i.e., local education agencies) to identify the strengths of the tool, any weaknesses or gaps, and any recommended modifications to the tool to make it better serve local public health practitioners. The revision of the tool was completed in the summer of 2012. Phase two of the project is piloting the revised tool. Through a combination request for applications and invitation process, AMCHP and NACCHO identified six local public health agencies (Chicago Department of Public Health, Illinois; New Britain Health Department, Connecticut; Union County Health Department, Ohio; Deschutes County Health Services, Oregon; Douglas County Health Department, Nebraska; Sedgwick County Health Department, Kansas) interested in piloting the revised tool and brought together the pilot teams for a kick-off meeting in September of 2012. AMCHP and NACCHO are using a concept called collective impact as the framework for the efforts. Collective impact, as defined by the original article Collective Impact in the Stanford Social Innovation Review, "is the commitment of a group of important actors from different sectors to a common agenda for solving a specific…problem." We felt that the framework would resonate with public health practitioners who have long recognized that complex societal problems cannot be solved by one organization alone (i.e., the health department) and require collaborative effort across and between organizations. Additionally, the framework was a natural fit given that the five conditions critical for collective impact to work – a common agenda, shared measurement, mutually reinforcing activities, continuous communication and backbone support – are very similar to what the ASC tool is designed to do: provide a structured process that leads to a common agenda (development of quality improvement plans), shared measurement, continuous communication and mutually reinforcing activities among all participants to improve adolescent health outcomes.

These efforts can only be realized, however, if the initiative has the infrastructure (time and resources and skills) to effectively support cooperative collaboration. In regard to the collective impact framework, the organization that spearheads the initiative is called the backbone organization. The backbone organization is responsible for bringing together the right stakeholders to dialogue about current efforts, reach consensus on gaps and priorities, help the group develop appropriate strategies to address them (or identify their particular niche in addressing them), and measure the success of the initiative. Successfully filling the role of the backbone organization requires a specific set of characteristics: a boundary-spanning approach to leadership; an ability to provide strategic direction; the ability to create a sense of urgency and need for a change; and the capacity to communicate effectively, mobilize stakeholders and, most importantly, facilitate productive dialogue. Anyone who has ever been a part of a collaborative effort can understand the critical importance of the ability to facilitate productive dialogue. Recognizing this, AMCHP and NACCHO invested in enhancing the skills of the pilot site teams by requiring attendance at a two-day Technology of Participation (ToP) facilitation training. Created by the Institute of Cultural Affairs, ToP techniques provide a structured process that enables a participatory, inclusive group process. AMCHP and NACCHO also provided some resource support in the form of small pockets of demonstration grants. Our hope, and the underlying theory behind building the capacity of our pilot sites, is that supporting their efforts to be effective backbone organizations will increase the likelihood of a successful initiative. Like any theory, however, the data will ultimately tell the story.

Over the past eight years of using the tool (it was first piloted in 2004), we have found that defining systems capacity can be challenging. What do we mean by systems? And, what do we mean by capacity? Systems are composed of many interconnected systems and subsystems. The adolescent health system, for example, includes many stakeholders outside of the health arena: education, juvenile justice, parks and recreation, and transportation to name a few. System capacity, in regards to adolescent health, is the overall ability of the system to address adolescent health effectively, efficiently and sustainably. Building system capacity requires key stakeholders, agencies, partners, entities, etc., to communicate and collaborate in order to leverage their efforts and maximize their impact on identified outcomes, in this case adolescent health. Effectively working together to achieve common outcomes is at the heart of collective impact. We are eagerly looking forward to seeing some of the change efforts that result from the local public health adolescent health assessments – and will be sharing insights and lessons learned.