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Suggested Citation:"Background." Institute of Medicine. 1996. Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience. Washington, DC: The National Academies Press. doi: 10.17226/5514.

The committee brought together expertise in state and local health departments, epidemiology, public health indicators, health data, environmental health, adult and pediatric clinical medicine, managed care, community health and consumer interests, quality assessment, health services research, and employer concerns. The group met six times between February 1995 and April 1996. Workshops held in conjunction with two of these meetings gave the committee an opportunity to learn more about conceptual and applied work relevant to performance monitoring and to hear about a variety of community experiences.

The Workshop

The committee's second workshop, held on December 11, 1995, is summarized here. The purpose of this workshop was to discuss both conceptual models underlying performance monitoring and its use in specific communities. Workshop presentations on conceptual models addressed the determinants of health, social change, and accountability. Presentations and a panel discussion gave five professionals working in communities an opportunity to bring to the committee comments and observations based on practical experience in health improvement programs and performance monitoring.

This summary of the workshop presentations and discussions is based on notes from the presentations, a transcript of the taped proceedings, and comments from the speakers. It does not present opinions, conclusions, or recommendations of the committee. Conclusions and recommendations, which will reflect consideration of the workshop discussions, will be presented in the committee's final report.

Background¹

As used by the committee, the term performance monitoring refers to a continuing community-based process of selecting indicators that can be used to measure the process and outcomes of an intervention strategy for health improvement, collecting and analyzing data on those indicators, and making the results available, to the community as a whole and specifically to those segments of the community engaged in health improvement activities, to inform assessments of the effectiveness of an intervention and the contributions of accountable entities. Performance monitoring should promote health improvement in a context of shared responsibility and accountability for achieving desired outcomes. Many parties within a community share responsibility for health (e.g., consumers, health care providers, businesses, government agencies,

¹	This section is based on comments by Thomas Inui.

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public service groups); those with responsibility for accomplishing specific tasks are accountable to the community for their performance.²

Several assumptions underlie the committee's approach to performance monitoring. First, it is increasingly necessary to use resources efficiently, that is, to accomplish tasks with a minimum of waste. Performance monitoring is expected to facilitate efficient approaches to improving the health of communities at a population level. Second, a performance monitoring system should have a broad enough perspective to monitor diverse factors that influence a community's health, including ones that may not appear obviously health related. Third, a wide range of actors share a stake in community health; thus, social action and changes that involve many sectors of the community are necessary. Finally, special attention to vulnerable populations is important, because equity is valued in community health.

The application of performance monitoring presents problems at the current level of knowledge and infrastructure. Although tools for indicator development exist, the conditions for creating operational monitoring systems at the community level may not. Furthermore, measurement strategies for an array of health issues are not universally available, and measures that are available may not always be applicable at the community level. In addition, most information systems are not yet able to support the identification and analysis of health problems and to track interventions.

A central task for the committee is the development of indicators suitable for community-based performance monitoring.³ Ideally, performance indicators measure states or critical processes that are potentially alterable and thought to have a demonstrable relationship to health outcomes. Those indicators may be measures of capacity, resources, processes, or actual health outcomes. Committee discussions suggest that indicator selection should be based on a

The committee's approach to performance monitoring relies on both the public health "core functions" of assessment and assurance (IOM, 1988) and the health care activities related to quality assessment, assurance, and improvement (see IOM, 1990). From a public health perspective, assessment is the regular collection, analysis, and dissemination of information on the health of the community. Assurance refers to a governmental responsibility to ensure that services necessary to achieve agreed upon goals are provided. Quality assessment refers to measurement of processes and outcomes of health care and their comparison against a standard. Quality assurance employs such measurement within the context of a broader set of activities that includes steps to identify and correct problems. Quality improvement uses continuous measurement and analysis of processes and outcomes not only to address problems but also to maintain and enhance good performance. The health improvement activities envisioned by the committee combine a responsibility to the community for achieving health goals with techniques like those used in quality improvement.

The indicators proposed by the committee will appear in the final report for this study.