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Improving Health in the Community: A Role for Performance Monitoring
sure to meaningful change in performance or health status; availability of data in a timely manner at a reasonable cost; opportunities to assign responsibility and accountability for performance; and inclusion in other monitoring systems (monitoring sets). Indicators must also be measurable; that is, it must be possible to formulate an operational definition that identifies units to be counted, a rate's numerator and denominator, or other appropriate components of a measurement.
Ideally, an indicator should meet all of these criteria, with the exception of inclusion in another monitoring system; in practice, limitations in knowledge and available data may make it appropriate to begin with usable measures while efforts are under way to develop better ones. Resources that communities might draw on to identify potential indicators include documents that cover many health issues, such as Healthy People 2000 (USDHHS, 1991) and its "midcourse" review (USDHHS, 1995); Healthy Communities 2000: Model Standards (APHA et al., 1991); and the Health Plan Employer Data and Information Set and Users Manual (HEDIS; NCQA, 1993, 1996). More specialized resources are also available (e.g., Walker and Richmond, 1984; National Committee for Injury Prevention and Control, 1989; AMBHA, 1995; Fawcett et al., 1995). In using these sources, communities need to look beyond measures of health status to indicators that link performance and outcomes, and beyond measures for a small set of stakeholder groups to indicators that encompass the entire community.
In a community setting, a variety of stakeholders should have the opportunity to participate in the selection of indicators through a mechanism such as a health coalition. For the examples presented here, a member of the committee or the study staff assumed primary responsibility for developing the materials on a given issue but was not necessarily an expert in that field. Comments were provided by other committee members, and for each health issue, advice was received from a small number of outside experts. As a result, the proposed indicators represent an informed but not definitive selection.
The committee focused its attention on performance measures applicable at the community level or to a broad category of community stakeholders (e.g., health plans, Medicaid participants, schools, employers, the elderly), not on measures applicable to a specific accountable entity in any stakeholder group. Recognizing that communities will differ in how a health issue presents itself, what resources and policy options are available, and who the accountable entities are, the committee concluded that it could not,