• Responsibility and accountability for performance. A critical element of performance monitoring is identifying where responsibility and accountability lie for actions that can improve health. It should be possible to link performance indicators to specific community stakeholders who have accepted or been assigned responsibility for some aspect of health improvement. In some cases, a stakeholder may have responsibility for a defined portion of the total population (e.g., health plans and their enrolled members, schools and enrolled students). When similar health needs exist in the remainder of the population, communities will have to determine where responsibility for serving that portion of the population lies.

Under some circumstances, a stakeholder may have to assume responsibility for producing or assuring the existence of an enabling precondition for achieving health improvement, rather than assuming more direct responsibility for the health outcome itself. Determining whether an "intermediate" activity such as this will be monitored at the community level or by an individual stakeholder organization will depend on a community's approach to the health issue and the nature of the precondition to be achieved.

• Robustness and responsiveness to change in health system performance, particularly in targeted populations. A performance indicator must be able to detect the effect of reasonably small changes in the performance system so that progress can be measured, even in small increments. If the performance indicator is unable to detect small initial changes, failure may be declared prematurely. Consideration must also be given to whether the indicator can reflect the impact of system changes on small subgroups in the population. In addition, indicators should be sufficiently stable and well defined that they are not subject to substantial random variation.

• Availability of data in a timely manner at a reasonable cost. The need to collect performance indicator data on a recurring basis makes ease and cost of collection important considerations. Because financial constraints are a concern for most communities, it will be imperative that performance indicators be measurable at reasonable cost and in a timely manner. Communities should consider the roles that the public and private sectors should each have in supporting data collection, analysis, and reporting.

• Inclusion in other indicator sets (monitoring sets). Some health-related indicator systems are already being used to assess