Balancing flexibility and accountability: Integrating performance measurement into an established federal public health program

Background: This presentation outlines the process and lessons learned in developing and implementing performance measures for the Preventive Health and Health Services Block Grant Program. Established in 1981, the program provides flexible funding to states, D.C., US territories, and Native American tribes to respond to critical local public health issues that cause illness, disability, and death. Balancing the states' need for flexibility to respond to local priorities and the funder's need to assess program impact was the major challenge. Description: We field-tested recommendations for overcoming the challenges of performance measurement in public health programs by: engaging key stakeholders in measure development, assessing the availability of data sources for measures, developing proxies for outcomes that are difficult to measure or for which data sources are limited, and piloting measures with Block Grant grantees of varied characteristics. Quantitative and qualitative data from the pilot sites informed system improvements and roll-out of the performance measures. Lessons Learned: Stakeholder engagement was critical for developing and implementing a balanced performance measurement system. In order to accommodate the history of the Block Grant's flexibility, and to make performance measure reporting acceptable to grantees, staffing and provision of technical assistance were emphasized. A structured menu of indicators can facilitate aggregation of performance measures data for funders. Recommendations: Stakeholder engagement in a participatory process is a necessary strategy for achieving a balance of accountability and flexibility in established programs that may resist the shift. Determining the appropriate mix of quantitative and qualitative reporting elements is also critical.