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Improving Health in the Community: A Role for Performance Monitoring
nize around an issue, with collective discussion, decision making, and action. Geography emerged as a critical point of reference in the committee's discussions. Although geographic (or civic) boundaries cannot adequately capture all of the potentially meaningful communities to which individuals might belong, they are a practical basis for analysis within the limitations of current data systems. Depending on the health issue, the relevant geographic unit (e.g., county, city, census tract) may vary.
A wide range of individuals, organizations, and agencies, many of whose roles are not within the traditional domain of health care or public health, have an effect on and a stake in a community's health (Patrick and Wickizer, 1995). These entities can include individual health care providers, public health agencies, health care organizations, purchasers of health services, and community organizations explicitly concerned with health. They can also include other government agencies (e.g., housing, human services, public safety), schools, business and industry, faith communities, and other community groups that may not usually be seen as having any explicit health-related role. Entities such as state health departments, federal agencies, managed care organizations, and national corporations have a broader scope than a single community but often have an important role at the local level.
As communities respond to the multiple factors involved in various health issues, all parties will have to sort out their roles and responsibilities. The specific pattern will vary over time and from community to community, depending on the mix and interaction of factors contributing to health. To optimize the unique contributions of these interdependent sectors, it will be important to address issues of accountability and shared responsibility for various aspects of community health. In most communities, there will be only limited experience with widespread collaborative or coordinated efforts among these diverse groups. A common language and an understanding of the multidimensional nature of the determinants of health will help community stakeholders work together effectively. Finding a way to accommodate diversity in values and goals will be another important task. Participation in the process of community-wide social change will also be needed for performance monitoring to succeed in improving health (Green and Kreuter, 1990).
The committee recognizes that there are limitations in a community-based approach to health improvement. Some of the factors affecting health in a community will originate elsewhere and may not be modifiable by efforts within the community. "Outside"