Over the course of the last three posts in this series (here, here, and here) we’ve looked at a high-level refresher on Results-Based Accountability (RBA), and population accountability in particular.
Just to jog your memory, RBA is an “ends-to-means” approach to creating and measuring change at the community (i.e., population) and program (i.e., organization or service) levels. It’s built around goals (result statements, or statements of desired well-being for specific populations) and five questions:
- How are we doing? (Looking at community indicators and/or program performance measures. We look for a trend and, if we don’t like the direction, we want to figure out how to make things better in the future or, “turn the curve.”)
- What’s the story? (What are the factors that are promoting or inhibiting beneficial outcomes?)
- What works? (What strategies can we employ to make progress towards the goal we’ve defined?)
- Who are our partners in turning the curve? (Who are we/can we/should we work with to make progress towards our goal?) and
- What’s our action plan? (What strategies are we going to pursue?)
Population accountability reminds us that our work exists as part of a bigger picture. Together, result statements and population accountability help us keep our focus at that high level.
From there, we looked at the first four RBA questions: How are we doing?, What’s the story?, What works?, and Who are our partners in turning the curve?
We’ll turn our attention to the last RBA question, “What’s our action plan?” This is the question that ties everything together, taking all of the talk and converting it to action.
Moving from Talk to Action
At this point in the process we get to decide which strategies we’ll pursue to turn the curve. We can choose strategies confidently because we’ve done the homework by thinking through the first four questions. The trick now is how to make the very best choices from a menu of excellent strategic options.
Choosing Strategies
Strategy selection involves balancing four considerations: leverage, feasibility, specificity, and values-alignment. Where possible, it’s a good idea to use an explicit scoring system to evaluate each strategy, but be sure that’s the starting point for discussion, not the final word. Strategies that score poorly on one or more criteria might easily be strengthened with one or a few tweaks. Alternatively, a strategy might be so off-the-charts amazing on an important criterion that you’re willing to live with some weakness on other criteria. So let’s now consider each criterion in a bit more depth.
To illustrate, we’ll take a look at a program run by our grant partner, Health Law Advocates (you’ll see more details as we walk through the strategy selection criteria). I do want to note that HLA didn’t explicitly use this Results-Based Accountability process in making decisions; it’s just a superb example of how these criteria and RBA principles more generally might show up in practice.
Leverage
Leverage is all about choosing strategies with the most potential to meaningfully turn the curve. Where can your strategy make the biggest difference for the most people?
Our grant partner, Health Law Advocates (HLA), illustrates the power of leverage through its Mental Health Advocacy Program for Kids (MHAP for Kids). When the Foundation first started funding the project about 13 years ago, it was called J-MHAP — Juvenile Court Mental Health Advocacy Project. J-MHAP worked exclusively with youth who were involved in the juvenile court system. HLA attorneys were appointed by the Juvenile Court as Mental Health Guardians Ad Litem, who worked to secure needed mental health, educational, and other supports for these youth. The program worked well, reaching many court-involved youths needing mental health support each year in Essex County (where we funded it) and Middlesex County.
A few years later, it became clear that the program would not be sustainable through the Juvenile Court system, so the choice was to run out grant funding using the existing model or to adopt a new strategy of working through the relatively new Family Resource Centers (FRCs) that were springing up across Massachusetts.
Today, MHAP for Kids is growing in leaps and bounds and has spread far beyond the small handful of sites we funded in Essex County. More important, it’s having a greater impact and doing more to turn the curve of access to mental health resources by operating through the FRCs. Shifting to the FRCs let HLA’s attorneys work with young people and their families before events led to involvement with the justice system. Intervening early means heading problems off before they grow to crisis proportions. That’s leverage.
What does this mean for your work? Look for opportunities to intervene before a problem is likely to occur (get “upstream”). Try to “snap up” and look for root causes — possibly at the systems level — for the issues you’re trying to address. See where your strategies can augment or amplify work that you (or others) are already doing.
Feasibility
RBA is all about getting from talk to action quickly. Feasibility makes sure we don’t waste time on strategies with no chance of success because they’ll never get off the ground. The very best strategy in the world won’t turn the curve if you can’t implement it. Does the strategy require more resources than you have? Does it require partners you don’t have relationships with already? Do you have enough time to implement the strategy? Do you have people who can implement the plan? Do you have the buy-in from all involved partners?
As you can imagine, there’s a lot to consider when deciding whether your strategy is feasible.
Looking at J-MHAP again, it was clear that financial resources were drying up, and the originally planned partnership with the Juvenile Courts wasn’t playing out as hoped. What were HLA’s options? Which was most feasible, short of giving up on the goal?
- Do nothing. Totally feasible, but not really in service of the goal of connecting youth needing mental health care to services.
- Try to force-fit the program into the Juvenile Courts. When the leadership of the juvenile courts changed, its priorities also shifted. The new leadership declined to support inclusion of funding for J-MHAP in the court’s budget, despite ongoing data collection indicating the program’s effectiveness. The buy-in just wasn’t there. That was a dead end.
- Find an alternative source of funding based on the existing model. The model was tailor-made for a juvenile court setting, so the only option here would be to pursue grant funding. Grants are fine as far as they go, but they’re generally pretty unreliable as long-term, sustainable funding. Again, not really a viable path forward.
- Tweak the model and look for funding sources. HLA firmly believed the program was a strong investment of public dollars because it consistently removed barriers to helpful mental health services for kids, diverting them from costly long-term hospitalizations and emergency room visits (paid for by Medicaid) and juvenile detention. (That wasn’t just speculation. The Foundation supported an outside evaluation that demonstrated J-MHAP”s efficacy. A bit more on that below.) J-MHAP had started as a tiny pilot program in 2005, and had always been based in the juvenile court; they needed to think outside the box.
The key was that they weren’t so wed to the initial model that they were closed to other possibilities. What if they could find another state agency partner that was prioritizing helping kids access mental health services before reaching the justice system? That’s where the Family Resource Centers came in. FRCs were gaining traction throughout Massachusetts, and the state was investing in their expansion. FRCs were a destination for families needing support; why not place attorneys there to help families get connected to services? HLA pitched the idea to the state’s Department of Children and Families and they agreed. Winner! The change in setting warranted a change in program name (since the J in J-MHAP stood for “Juvenile Court”), giving us MHAP for Kids.
Soon after launching MHAP for Kids in the FRCs, the Boston University School of Public Health (BUSPH) published its first evaluation of the court-based model. It showed the program achieved remarkably positive results, including significantly improving kids’ mental health. The Massachusetts state Senate saw the extraordinary potential of the program and included some funding for MHAP for Kids in the state budget. As a result, there was, between our grant funding and the state funding, money to sustain attorneys in a couple of FRCs. There was an evaluation partner who could continue to document the program’s benefits for families. There was enough time to implement the change and build the case for expansion. In short: This was a feasible action plan.
A lot of things needed to line up for this to work out as well as it did. The key elements here were that HLA took a hard look at time, resources, political will, and — perhaps most important — what was essential to the model and what needed to be changed to be viable.
Specificity
RBA looks for strategies to have high specificity: clear, measurable actions that can be implemented effectively. Vague ideas and notions don’t lend themselves well to implementation.
An action plan requires specificity to get going: it needs clear actions to be taken, clearly identified parties who are responsible for each action, deadlines, measurable goals, and a clear idea of what resources are required.
Once HLA made the decision to shift J-MHAP in the Juvenile Courts to MHAP for Kids at the FRCs, it was time to get truly tactical. They had a little breathing room, as they had found a new home for the then-fully grant-funded program with an enthusiastic partner in DCF and enough grants were coming in to demonstrate the program’s vitality until state funding could become a reality. HLA cultivated relationships with its new allies in the Department of Children and Families and developed detailed budget projections and program protocols to present to legislators along with the evaluation report from BUSPH. They had a talented law student draft a manual for launching new MHAP for Kids sites in other FRCs. Ultimately, this legwork allowed them to secure the appropriation in the state budget (modest at first — $50,000; now much larger!). They had clarity on the program’s structure and a path forward. The goal was clear: ensure a successful transition to the FRCs and continue helping families.
As you choose your strategies, you want to make sure you have this same level of specificity and concreteness. It’s tempting to look at a plan and think, “I’ve got this” without getting into the weeds: that’s dangerous. Get detailed, concrete, and into the weeds — only then will you really know whether you have a plan that’s ready to be implemented.
Values-Alignment
While it might seem obvious, you do need to consider whether the strategy you’re looking at is consistent with your organization’s, your coalition’s, or your own personal values. There are many ways to accomplish change, but not all of them are equally palatable.
In RBA, how you achieve results matters just as much as the results themselves. For example, a youth-serving organization could potentially show better short-term outcomes by cherry-picking the easiest-to-serve clients, but this approach would likely conflict with values of equity and inclusion.
The MHAP for Kids example demonstrates values-alignment in action. When HLA was considering alternatives to the court-based model, they could have pursued strategies like:
- narrowing their focus to only the most straightforward cases;
- dropping their attorney-based advocacy model in favor of less intensive approaches; or
- limiting services to families who could contribute financially (this was never really an option).
Instead, they chose a path that aligned with their values of access, equity, and comprehensive support. By moving to the FRCs, they maintained their commitment to providing high-quality advocacy for youth and families while expanding reach to families who might otherwise fall through the cracks of the system. In this instance, being pushed to re-evaluate their model might even have resulted in a more values-aligned approach than the original!
When assessing values-alignment in your own strategies, consider asking:
- Does this strategy treat all stakeholders with dignity and respect?
- Would we be proud to publicly share how this strategy works?
- Does this approach reflect the priorities of the communities we serve?
- Are we compromising any core values to achieve short-term gains?
Values-aligned strategies build trust and sustainability. When your methods align with your values (and those of the community you’re serving), you’re more likely to maintain stakeholder support, stay the course over time (results don’t happen overnight!), and create truly durable change.
Using the Five RBA Questions
One of RBA’s great strengths is that once you’ve decided on and implemented a strategy, the model itself effectively drives all project meeting agendas! If you consider each question in order over the course of a meeting, you almost can’t help but drive progress on your results. For each strategy or project you’ve got underway, ask (and answer) the five RBA questions:
- How are we doing? (Review your community indicators — if they’ve been updated recently — and program performance measures. Are things trending in the right direction?)
- What’s the story? (Irrespective of how things are trending, ask yourself what factors are helping or hurting your desired progress.)
- What works? (Is our current strategy working? What parts are working, what parts aren’t? How can we adjust them to increase effectiveness?)
- Who are our partners in turning the curve? (How are we doing with our current partners? Should be we adding more partners? If so, whom and how do they fit into the strategy?) and
- What’s our action plan? (What specific actions do we need to take next?)
It might seem a little rote, but this structure creates a continuous learning and improvement cycle. As you move through these questions meeting after meeting, you’ll build on what you’ve learned previously, track your progress, identify challenges early, and adjust your strategies based on data rather than hunches. More important, it keeps everyone’s eyes on the prize: turning the curve on the results you care about.
The five-question framework also prevents common meeting pitfalls. We’ve all sat through meetings that get bogged down in mind-numbing details or that devolve into gripe sessions without ever getting to solutions. When a meeting starts to wander off into the weeds, it’s easy to bring everyone back by saying, ‘Let’s get back to the question we’re trying to answer here.’ It’s a simple way to stay focused and productive.
Stay Tuned: In Our Next Episode…
The final post of this series will focus on assessing how effectively we’re implementing our strategies. This is where the last key RBA concept, performance accountability, enters the picture.