Improving Health in the Community A Role for Performance Monitoring (1997) / Chapter Skim
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4 A Community Health Improvement Process
4 A Community Health Improvement Process
Pages 77-125
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From page 77... ...
This chapter describes a community health improvement process that provides such a framework. Critical to this process are performance monitoring activities to ensure that appropriate steps are being taken by responsible parties and that those actions are having the intended impact on health in the community.
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A CHIP must also 1The CHIP acronym adopted for this report is not unique to the community health improvement process. In a health context, others use it to refer to community health information programs/partnerships/profiles.
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A COMMUNITY HEALTH IMPROVEMENT PROCESS 79 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 4-1 The community health improvement process (CHIP)
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From page 80... ...
One-time activities, briefly assembled coalitions, and isolated solutions will not be adequate. A CHIP should not hinder effective and efficient operation of the accountable entities in the community that are expected to respond to specific health issues, and it must be able to accommodate the dynamic nature of communities and the interdependence of community activities.
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In Massachusetts, for example, which has only one county health department, the state has taken a lead by establishing 27 Community Health Network Areas (CHNAs; see Chapter 3) to serve as the base for local health improvement activities (Massachusetts Department of Public Health, 1995)
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. The basic Plan– Do–Check–Act cycle used in CQI is being applied to community health programs (Nolan and Knapp, 1996; Zablocki, 1996)
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. Although performance monitoring is not an explicit focus of COPC, this approach to health care emphasizes the importance of community-based data for understanding the origins of health problems.
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, provides an eightstep process for assessing community health, assembling a community-based group through which to work, identifying and prioritizing issues of concern, and formulating a plan for responding. The APEXPH process is designed to begin with action by a local health department, but initial steps can also be taken by others in the community.
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Kaiser Family Foundation Community Health Promotion Grant Program (Tarlov et al., 1987)
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The current health planning and health assessment models provide a comprehensive community perspective but generally put less emphasis on the linkage between performance monitoring and stakeholder accountability than either the problem identification and prioritization cycle or the analysis and implementation cycle of the proposed CHIP. The quality improvement and performance measurement activities that have developed in the personal health care sector bring accountability for performance to the fore explicitly.
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From page 87... ...
That will be an essential step in validating and improving the process. PROBLEM IDENTIFICATION AND PRIORITIZATION CYCLE As proposed by the committee, the problem identification and prioritization cycle has three main phases: • forming a community health coalition; • collecting and analyzing data for a community health profile; and • identifying high-priority health issues.
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Because community health and resources are influenced by factors such as federal and state programs and policies and by private-sector activities such as corporate practices and accreditation standards, communities should consider how those perspectives can be represented in a coalition. In the committee's view, inclusiveness is an important principle for these coalitions, but it recognizes that some activities may warrant attention from a more strategically focused group of participants.
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Collect, Analyze, and Publicize Community Health Data Another phase of the problem identification and prioritization cycle is assessing the community's health status and health needs
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The tools and worksheets are intended to help communities organize their members, assess community health status, prioritize community health issues, and develop effective in terventions for improving community health. Two of the manuals focus specifically on coalition issues.
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The community health coalition should oversee the development and use of a health profile, but responsibility for data collection and analysis may lie with particular coalition participants that have resources suited to specific tasks. Health departments, in particular, have health assessment as a core function (IOM, 1988)
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. To ensure access to essential data, however, the committee recommends that states and the federal government require that certain standard data be reported, including data on the characteristics and health status of enrolled populations, on services provided, and on outcomes of those services.
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. Identify Critical Health Issues The third phase of the problem identification and prioritization cycle is identifying those health issues that are of special concern to the community and determining which ones should be given the highest priority for additional attention.
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The committee urges community coalitions to begin addressing specific health issues even if initial efforts are directed to topics that might not be seen by all as the "most important" ones. Communities should expect to develop, over time and as resources permit, a "portfolio" of health initiatives.
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Important benefits of interventions that target critical developmental periods for infants and young children, for example, may not be evident until adolescence or adulthood. Communities and their coalitions should, however, guard against overemphasizing issues that are visible but have limited impact on community health.
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Expert advice can be especially valuable when the determinants of health status are less well understood. Such advice can help coalition participants, and the larger community, to interpret the available evidence and determine how the accepted "best practices" can be applied to meet the community's needs.
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APEXPH focuses in particular on the capacity of the local health department to perform a variety of functions important for health improvement activities such as building community constituencies, collecting and analyzing data, and developing and implementing health policy. The experience of McHenry County, Illinois, described briefly in Box 4-2, illustrates one community's approach to a specific health concern.
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From page 98... ...
Following the APEXPH process (NACHO, 1991) , the Community Health Committee re viewed IPLAN data provided by the state health department on the county's sociodemographic characteristics, general health status, and specific health issues such as maternal and child health, chronic disease, infectious dis ease, environmental health, injury, and access to care.
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Establish Accountability for Health Improvement Activities Establishing accountability is a key to using performance monitoring in the health improvement process proposed by the committee. Specific entities must be willing to be held accountable for undertaking activities, within an overall strategy for dealing with a health issue, that are expected to contribute to achieving desired outcomes.
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In contrast to a community health profile, which provides an overview of health status and community characteristics, performance indicators focus on a specific health issue and the activities undertaken as part of a health improvement strategy. Because health issues have many dimensions and can be addressed by various sectors in the community, sets of indicators will be needed to make a meaningful assessment of overall performance.
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A review of existing indicator sets may suggest measures that could be adopted for community use and may be a source of tested operational definitions.2 The development of indicator sets and the selection of indicators are discussed in greater detail in Chapter 5. Appendix A illustrates the application of the committee's proposals with prototypical sets of community-level performance indicators for several specific health issues.
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As for the community health profile, it will be important to examine these quantitative indicators in conjunction with qualitative information that can contribute to a more complete picture of the community context. Valuable information about the imple
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As noted above in the discussion of community profiles, the committee recommends requiring that health plans, indemnity insurers, and other private-sector entities report standard types of data. The principle of helping meet the community's information needs should extend to providing more specialized data in support of performance monitoring focused on a specific health issue.
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Efforts to improve the CHIP itself can serve as a model for the improvement process being applied to community health issues. A learning approach should be applied not only to the process but also to the science base for health improvement activities.
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These communities should differ in terms of size, political structure, socioeconomic and racial composition, region of the country, and specific health issues addressed. There should also be differences in how the health improvement process is operationalized in terms of the composition of the community coalition, how health issues are identified, the way in which performance indicators are selected and monitored, and the role played by state and local health departments.
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should be considered in developing a framework for an assessment of the community health improvement process. In addition, experience gained in evaluating multisectorial community programs that target social issues other than health can also help inform these assessment efforts (Connell et al., 1995)
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A review of experiences in planning and implementing these projects suggests several opportunities to move the health improvement process ahead more quickly: • a large-scale community assessment need not be a prerequisite for initiatives on specific health issues; • more than one approach can be followed in addressing a health is sue; • the overall goal of the intervention should be clear but a single point of control for activities undertaken by separate groups is not essential; • implementation plans should include at least one step expected to produce a change within the first few months of a project; • planned interventions should be tested on a small scale and revised as needed before pursuing community-wide implementation; • once a test shows that an intervention can lead to improvements, support should be sought for more widespread implementation; • participation by subject matter experts can help planning and imple mentation move more quickly; and • information on similar efforts in other communities can suggest both opportunities and potential problems. SOURCE: Knapp and Hotopp (1995)
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, proposes the following set of capacities: health assessment, including data monitoring and analysis; policy development; administration; health promotion; health protection; quality assurance; training and education for competent staff; and 4The essential public health services have been defined as (1) monitor health status to identify and solve community health problems; (2)
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Looking to the future, the Pew Health Professions Commission (1995) has proposed a set of "competencies" that the health professions should develop and enhance over the next decade (e.g., care for the community's health, clinical competence, prevention and health promotion, appropriate use of technology)
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Where a CHIP can be instituted, the community coalition, or other agents of the process, will require a varied set of capacities to carry out all phases of the process. The ability to organize and sustain a CHIP, including the performance monitoring elements, is key.
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Certain forms of data collection, for example, must have official sanction and must meet requirements for adequate protection of privacy and confidentiality. The implementation of specific health improvement strategies might also depend on having formal authority to act in the community at large or within a specific setting (e.g., to enforce environmental regulations, change a workplace smoking policy, or co-locate an immunization clinic with a public assistance office)
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Expertise in these areas can be applied to health prob lems of all types. The need for such expertise is well recog nized, if not always available, in state and local health departments.
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Although a wide variety of excellent resources on community health assessment and CQI currently exist, those materials generally do not link assessment and CQI concepts and techniques in the way that is envisioned for a CHIP. Therefore, in the committee's view, federal agencies, national professional organizations, and foundations should provide leadership to promote the development of new and better tools that can help communities achieve success with the proposed health improvement process.
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In addition, each of the state's 33 local health jurisdictions is expected to facilitate a comprehensive community health assessment process and the development of a report that presents locally derived health indicators as well as community risk and protective factors for a defined geographic area. These assessments are used to set community priorities for population-based activi ties through the public health system and its many partners.
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The committee believes that states have a special responsibility to assist communities in obtaining data for community health profiles. There is also a need for further development of performance measurement tools to make the health improvement process more effective.
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. Although this work currently relies primarily on a health care provider perspective, the potential would seem to exist to adopt a broader approach that can support community health improvement activities (Milio, 1995)
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CONCLUSIONS In this chapter, the committee has laid out the framework for an iterative and evolving community health improvement process that relies on collaboration among a diversity of stakeholders and uses measurement as a tool for establishing stakeholder accountability for contributions to that process. The broad perspective that the field model provides on health and the factors contributing to it gives a CHIP a basis for seeking opportunities for health improvement throughout the community, not just within the health department or the health care provider's office.
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1994. Health Reform and the Health of the Public: Forging Community Health Partnerships.
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1991. Consensus Set of Health Status Indicators for the General Assessment of Community Health Status -- United States.
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How-to Guides on Community Health Promotion, No.
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1995. Applying TQM to Community Health Improve ment: Nine Works in Progress.
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1996. CHART: Community Health Assessment Resource Team [WWW document]
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National Civic League.
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1988. Community Health Planning in the United States: A Post Mortem.
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1996. Improving Community Health Status: Strategies for Success.
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