Improving Health in the Community A Role for Performance Monitoring (1997) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-22
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Committee on Using Performance Monitoring to Improve Community Health draws on lessons from a variety of current activities to outline the elements of a community health improvement process, discuss the role that performance monitoring can play in this process, and propose tools to help communities develop performance indicators. BACKGROUND The report reflects three important developments: (1)
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This multidimensional perspective reinforces the value of public health's traditional emphasis on a population-based approach to community health issues. A Community Perspective The array of influences on health identified by the field model also suggests that there are many public and private entities that have a stake in or can affect the community's health.
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These interdependent sectors must address issues of shared responsibility for various aspects of community health and individual accountability for their actions. They also must participate in a process of community-wide social change that is necessary for health improvement efforts and related performance monitoring to succeed (Green and Kreuter, 1990)
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As used by the committee, the term "performance monitoring" applies 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 to inform assessments of the effectiveness of an intervention and the contributions of accountable entities. Performance monitoring should promote health in a context of shared responsibility and individual accountability for achieving desired outcomes.
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Performance monitoring is the tool that communities can then use to hold community entities accountable for actions for which they have accepted responsibility. Based on its review of the determinants of health, the community-level forces that can influence them, and community experience with performance monitoring, the committee finds that a community health improvement process (CHIP)
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6 IMPROVING HEALTH IN THE COMMUNITY Form Community Prepare and Analyze Health Coalition Community Health Profiles Problem Identification and Prioritization Cycle Identify Critical Health Issues Health Issue Health Issue Health Issue Analyze Health Issue Monitor Process Inventory Resources and Outcomes Analysis and Implementation Implement Cycle Develop Health Strategy Improvement Strategy Develop Identify Indicator Set Accountability FIGURE 2 The community health improvement process (CHIP)
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Alternatively, a general interest in health might stimulate formation of a coalition, data collection activities, and development of options for strategic actions. The health assessment activities that are part of the problem identification and prioritization cycle should include production of a community health profile that can provide basic information to a community about its demographic and socioeconomic characteristics and its health status and health risks.
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A community may have a portfolio of health improvement activities, each progressing through this cycle at its own pace. Analyze the Health Issue A community, through its health coalition or a designated agent such as the health department, must analyze the health issue to understand the contributing factors and how they operate in the community.
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. Develop a Health Improvement Strategy Health improvement strategies should seek to apply available resources as effectively as possible, given a community's specific features.
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Establish Accountability for Activities Establishing accountability through a collaborative approach is a key to using performance monitoring in the health improvement process proposed by the committee. Specific entities must be willing to be accountable to the community for undertaking activities that are expected to contribute to achieving desired health outcomes.
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. The committee cannot prescribe what actions individual communities should take to address their health concerns or who should be responsible for what, but it does believe that communities need to address these issues and that an organized approach to health improvement that makes use of performance monitoring tools will help them achieve their goals.
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Thus, the committee recommends that • a CHIP should develop its own set of specific, quantitative performance measures, linking accountable entities to the performance of specific activities expected to lead to the production of desired health outcomes in the community. Selecting these indicators will require careful consideration of how to gain insight into progress achieved in the health improvement process.
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for understanding factors that contribute to the production of health, salience to community stakeholders, and support for the social change processes needed to achieve health improvements. Other proposed criteria are validity and reliability, availability of evidence linking performance and health improvement, sensitivity to changes in community health status, and availability of timely data at a reasonable cost.
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The proposed health improvement process and performance monitoring activities will require that communities have a sustainable system that provides for participation by major stakeholders and accountable entities. Thus, the committee recommends that • community coalitions guiding CHIPs should strive for strategic inclusiveness, incorporating individuals, groups, and organizations that have an interest in health outcomes, can take actions necessary to improve community health, or can contribute data and analytic capabilities needed for performance monitoring.
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Since all parties share in the goal of improving community health, it is reasonable to combine public and private resources to support the data collection and analysis needed for communities to obtain health profile information, to conduct health status assessments and communicate results, and to sustain performance monitoring pro
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can assist communities by facilitating access to relevant data held by the private sector. In particular, the committee recommends that • states and the federal government, through health departments or other appropriate channels, should require that health plans, indemnity insurers, and other private entities report standard data on the characteristics and health status of their enrolled populations, on services provided, and on outcomes of those services, as necessary for performance monitoring in the community health improvement process.
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Not found, however, was a conceptual framework for using performance monitoring concepts to improve community health as a whole (as opposed to monitoring the performance of specific entities such as managed care organizations or public health agencies)
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Thus, the committee recommends that • the Public Health Service, in conjunction with state and local health agencies, national professional organizations, and foundations, should develop standard measures for community health profiles and topic-specific model indicator sets that perform well in individual communities and are suitable for cross-community comparison. These standard measures would be a resource available to communities, not a set of prescribed measures.
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that can be applied to community-level performance monitoring should be supported as well. More generally, technical expertise based on experience with the community health improvement process must be developed and shared.
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American Journal of Epidemiology 142:569– 575. NACHO (National Association of County Health Officials)
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1996. Improving Community Health Status: Strategies for Success.
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