propriate in relation to expected health benefits. For many health issues, however, evidence for effective interventions will be limited. A community should not ignore those issues but will have to consider carefully what actions will make the best use of its resources. Communities should also consider the implications of not acting on a health issue.

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. The committee sees a collective responsibility among all segments of a community to contribute to health improvements, but each entity must accept individual responsibility for performing those tasks that are consistent with its capabilities.

Develop a Set of Performance Indicators

Performance indicators are needed to help community stakeholders monitor whether the health improvement strategy is being implemented as intended and whether it is having the intended impact. These quantitative measures must apply to specific entities in the community that have accepted responsibility for some aspect of the health improvement effort. Because health issues have many dimensions and can be addressed by various sectors in the community, sets of indicators will be needed to assess performance.

Implement the Improvement Strategy

Implementation of health improvement strategies and interventions requires action by many segments of a community. The particular mix of activities and participants will depend on the health issue being addressed and on a community's organization and resources. In most instances, these activities will require the involvement of both public- and private-sector entities and often of entities that may not traditionally be seen as part of the health system.

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