C Using Performance Monitoring to Improve Community Health: Exploring the Issues

Workshop Summary1

SUMMARY

Performance monitoring is being used as a tool for evaluating the delivery of personal health care services and for examining population-based public health activities. The Institute of Medicine's Committee on Using Performance Monitoring to Improve Community Health is exploring how such efforts might be coordinated and directed toward improving the health of entire communities. The committee is considering the individual and interrelated roles that public health agencies, health care providers in the private sector, and various other stakeholders play in influencing community-wide health; how the performance of those roles can be monitored in a systematic manner; and how a performance monitoring system can foster collaboration among stakeholders and promote improvements in health status for all members of the community. An important task for the committee will be developing prototypical sets of indicators that communities can use to monitor specific health issues and the role that public health agencies, personal health care organizations, and other

1  

This appendix is an abridged version of a workshop summary published separately as Using Performance Monitoring to Improve Community Health: Exploring the Issues (Institute of Medicine [1996], J.S. Durch, ed.; Washington, D.C.: National Academy Press).



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Improving Health in the Community: A Role for Performance Monitoring C Using Performance Monitoring to Improve Community Health: Exploring the Issues Workshop Summary1 SUMMARY Performance monitoring is being used as a tool for evaluating the delivery of personal health care services and for examining population-based public health activities. The Institute of Medicine's Committee on Using Performance Monitoring to Improve Community Health is exploring how such efforts might be coordinated and directed toward improving the health of entire communities. The committee is considering the individual and interrelated roles that public health agencies, health care providers in the private sector, and various other stakeholders play in influencing community-wide health; how the performance of those roles can be monitored in a systematic manner; and how a performance monitoring system can foster collaboration among stakeholders and promote improvements in health status for all members of the community. An important task for the committee will be developing prototypical sets of indicators that communities can use to monitor specific health issues and the role that public health agencies, personal health care organizations, and other 1   This appendix is an abridged version of a workshop summary published separately as Using Performance Monitoring to Improve Community Health: Exploring the Issues (Institute of Medicine [1996], J.S. Durch, ed.; Washington, D.C.: National Academy Press).

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Improving Health in the Community: A Role for Performance Monitoring entities with a stake in these matters could be expected to play in addressing those issues. The study is funded by the U.S. Department of Health and Human Services and by The Robert Wood Johnson Foundation. A May 1995 workshop reviewed a variety of public and private activities in health-related performance monitoring. An opening presentation focused on conducting and using an assessment of health status in New York City's Washington Heights/Inwood neighborhood. The subsequent presentation explored characteristics and limitations of health plan performance indicators and how they might be applied in a broader community context. The final presentation in this portion of the workshop reviewed the development of measures of public health practice for assessing the performance of local health departments and Illinois's application of such assessments in certification of its local health departments. A set of presentations on Washington State and Seattle-King County included discussions of the state health department's focal role in public health policy; links between the University of Washington School of Public Health and the state's local health departments; the community-oriented approach of the private nonprofit Group Health Cooperative of Puget Sound; efforts to bring a health outcomes perspective to assessments of environmental health activities; the state's voluntary public-private collaboration in the development of health data systems; and an overview of the health assessment and monitoring program in Seattle-King County. Final presentations reviewed activities of several federal agencies and national organizations, including work on clinical performance measures and health plan reporting; the national health promotion and disease prevention objectives of Healthy People 2000; tools to help communities and local health departments assess health needs and set objectives for improvement; and proposals for linking federal block grants in specific health areas to state performance commitments. The presentations and discussion highlighted several points. Identifying shared interests that can promote collaboration in meeting health needs will be important. Throughout the workshop, consulting with the community was emphasized as an important means of learning about areas of concern, gaining a better understanding of the data collected, and building support within the community for the monitoring process. Public health agen-

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Improving Health in the Community: A Role for Performance Monitoring cies can often play a valuable role in initiating and sustaining community collaboration. Applying performance monitoring to community health issues will require population-based data at the community level, but some communities will need to expand their capacity for data collection and analysis. A determinants-of-health framework helps demonstrate the need for information on clinical services plus environmental health and other factors such as education and social services that have an impact on health. Assembling data from a variety of public and private sources avoids duplication of effort in data collection and provides a more complete picture. Better evidence on the impact of many community health interventions on health status are needed. Schools of public health may be to able to assist performance monitoring efforts by conducting research on the effectiveness of interventions, providing analytic training for public health practitioners, and serving as source of expert advice for communities. Any effort to propose a model for a performance monitoring system must take into account the social, political, economic, and organizational differences among states and communities, all of which influence capacity and willingness to address community health. An assessment of how well private sector health plans are serving their members and the community is seen by many as an appropriate element of the community monitoring process. Questions arise, however, about the extent to which health plans can and should be held accountable for the health status of all residents in the community. Also important is understanding how to achieve constructive change. Differences across communities and among the participants and audiences within communities emphasize the need for the committee to discuss performance monitoring in a way that is understandable from many perspectives. INTRODUCTION As part of its effort to collect information on current and planned performance monitoring activities, the Institute of Medicine (IOM) Committee on Using Performance Monitoring to Improve Community Health held a workshop on May 24–25, 1995. The workshop gave the committee the opportunity to meet with researchers studying performance monitoring and with representatives of public and private organizations conducting or developing performance monitoring activities. This report summarizes

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Improving Health in the Community: A Role for Performance Monitoring the workshop presentations and discussion. It does not present any formal recommendations or conclusions from the committee. CONNECTING WITH THE COMMUNITY Improving the health of communities requires looking beyond the contributions of medical care and providers of personal health care services. Similarly, measures of community health must be based on a broader population than those who have received medical care or who are members of a particular health plan. The first two presentations gave the committee an opportunity to learn about projects based on building links between the medical and the community perspectives. Assessing a Community's Health2 Washington Heights/Inwood is a neighborhood of about 200,000 residents, predominantly lower income and Latino, in the northern part of Manhattan in New York City. It also is the home of Columbia Presbyterian Medical Center. In producing Washington Heights/Inwood: The Health of a Community (Garfield and Abramson, 1994), the Health of the Public Program at Columbia University used data gathering for an assessment of the community's health as a way to build better ties between the academic health center and the community. The report, which has proved useful to many different groups, presents a broad range of information about the community, including health-related data (e.g., death rates and immunization rates) and health services measures (e.g., ambulatory care visits and inpatient insurance status). Also presented are data on characteristics of the community that can influence health, such as ethnicity, immigration status, household composition, per capita income, and educational attainment. For many measures, the report shows that Washington Heights/Inwood has relatively good health status. Household stability among the predominantly immigrant population may be a factor. The neighborhood is not without health problems, however. Of particular concern are violence, AIDS, and teen pregnancy. The discussion also emphasized the need to consult with the likely audience for such reports to identify issues of interest and 2   This section is based on a presentation by Richard Garfield.

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Improving Health in the Community: A Role for Performance Monitoring potential sources of data, and to produce data and reports that are understandable to a broad audience. Involving the community and responding to its concerns may increase the community's interest in and acceptance of the findings, particularly negative ones. Adapting Health Plan Performance Indicators for the Community3 The Center for the Advancement of Health in Washington, D.C., in connection with the California Wellness Foundation's Health Improvement Initiative, has considered how performance indicators developed for health plans might become a tool for accountability to stakeholders in communities served by health plans (see Sofaer, 1995). These stakeholders include consumers, employers, and public agencies, including regulators. The Center's expanded view of health emphasizes psychosocial and behavioral aspects of the delivery of health services and a public health perspective for the assessment of services to improve health. The project identified several functions of performance indicators: specifying criteria for evaluation and values regarding health and health services; making explicit the expectations for some aspects of health care delivery; providing information for decisions on health services; supporting quality assessment and improvement; and, potentially, guiding the development of information systems. Further consideration focused on the normative, technical, strategic, and operational aspects of performance indicators. The normative element reflects value judgments made in selecting areas of performance (i.e., health outcomes) for which health plans or other organizations or individuals will be held accountable. Technical aspects of performance indicators include measurement issues such as the quality of the data being used and the validity and reliability of the indicators. Indicators must also permit meaningful comparisons across entities. Strategic concerns relate to the purposes indicators are expected to serve. The appropriate number, focus, and mix of indicators (e.g., outcomes versus structure or process) require consideration as does setting targets for desired performance at levels that will lead to meaningful improvements. Operational issues include the feasibility of obtaining data and approaches to disseminating results. 3   This section is based on a presentation by Shoshanna Sofaer.

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Improving Health in the Community: A Role for Performance Monitoring A review by the Center for the Advancement of Health and the Western Consortium for Public Health (1995) of many activities in the public and private sectors to develop and use performance indicators examined the extent to which the indicators addressed a range of consumer and community health concerns. They found a focus on the performance of individual providers and the use of health services. With programs such as the Health Plan Employer Data and Information Set (HEDIS), which the National Committee for Quality Assurance (NCQA, 1993) now sponsors, measures are moving beyond users of health services to entire enrolled populations in managed care plans. Several "gaps" were noted among the indicators that were reviewed, including individuals' functional status, health-related quality of life, and behavioral and psychosocial aspects of illness and health care. Mental health and substance abuse services receive some attention, but they are often provided by separate specialty groups, making it difficult to identify problems in integrating psychosocial services with other forms of care. Determining appropriate indicators for multidimensional health problems is also a concern. Regarding accountability, one concern is reaching agreement among stakeholders on where accountability for health outcomes can and should lie. In particular, the role that private sector health plans (and other medical care providers) should be expected to play in community-based health improvement efforts is a source of concern and debate. Currently, employers are a principal locus of oversight and influence in "operationalizing" accountability. It is not clear whether the plan selections made by individual consumers will have sufficient impact. Regulatory requirements are possible but may not be optimal. Some health plans are willing to accept limited responsibility for elements of community health but others may not yet be ready to so. ASSESSING COMMUNITY PUBLIC HEALTH PRACTICE4 Federal, state, and local public health agencies have special responsibilities for protecting and improving community health. The Future of Public Health (IOM, 1988) defined their core functions as assessment of health status and health needs, policy development, and assurance that necessary health services are 4   This section is based on a presentation by Bernard Turnock.

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Improving Health in the Community: A Role for Performance Monitoring available. Healthy People 2000: National Health Promotion and Disease Prevention Objectives (USDHHS, 1991) included as Objective 8.14 that 90 percent of the population be served by local health departments that are effectively carrying out the core functions of public health. Work is now under way to develop measures of effective public health performance to assess progress toward this Healthy People 2000 objective that states and communities can use to monitor and improve public health practice. Developing Performance Measures for Public Health Practice The workshop presentation focused on activities based at the University of Illinois at Chicago (see Turnock et al., 1994a, 1994b, 1995) and also drew on collaborative work with the University of North Carolina (UNC) (see Miller et al., 1994a, 1994b). The work at the University of Illinois at Chicago has focused on developing a measurement tool for the Healthy People 2000 objective on the performance of local health departments. In contrast, the project at UNC is developing self-assessment tools for local health departments. These efforts, and a third project at the University of South Florida (see Studnicki et al., 1994), have been encouraged by the Public Health Practice Program Office of the Centers for Disease Control and Prevention (CDC). Efforts to measure the performance of local public health departments have focused on process—public health practice—rather than on inputs, outputs (e.g., specific programs or services), or health outcomes. A set of 10 practices has been linked to the core public health functions of assessment, policy development, and assurance. Using sources such as APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991) and Healthy Communities 2000: Model Standards (APHA et al., 1991), the University of Illinois at Chicago project selected a set of public health practice indicators and sent them to a panel of local health officials for review. After revisions, the indicators were sent to a national sample of local health departments for comments on issues such as whether the indicators were important descriptors of local public health practice and whether proposed measures were appropriate. Most recently a set of 20 indicators that merge the results of the work at the University of Illinois at Chicago and UNC have been developed and tested. The indicators reflect standards for

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Improving Health in the Community: A Role for Performance Monitoring both performance and capacity to perform. For example, for assessment practices the selected indicators include whether there is a community health needs assessment process and whether adequate laboratory facilities exist to meet diagnostic and surveillance needs. Using Public Health Performance Measurement Information from monitoring public health performance has various applications. At the national level, the measurement tools being developed provide a way to monitor progress toward the Healthy People 2000 objective of having 90 percent of the population served by local health departments effectively carrying out core public health functions. States and communities can use this kind of information to identify practice areas that need attention and to track changes in performance and the circumstances associated with those changes. National Surveillance Responses from the University of Illinois at Chicago's survey of local health departments indicated that, on average, those health departments performed about 50 percent of the activities associated with the 10 public health practices. Overall, health departments performed more practices related to the assurance function than those related to assessment or policy development. Survey responses suggest that, in terms of the Healthy People 2000 objective, about 20–30 percent of health departments, serving about 40 percent of the population of the United States, had an ''effective" level of performance (Turnock et al., 1994b). Application in Illinois In 1992 and 1994, the performance of local Illinois health departments was assessed using a set of 26 measures of public health practice (see Turnock et al., 1995). Between 1992 and 1994, the percentage of practices performed rose from an average of 55 percent to an average of 85 percent. Several changes contributed to the improved performance, including the state's requirement that local health departments conduct assessments based on the APEXPH model (NACHO, 1991) or on an Illinois version called IPLAN (Illinois Plan for Local Assessment of Needs). Community health assessment was implemented through a col-

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Improving Health in the Community: A Role for Performance Monitoring laboration between the state and the local health departments. For most local health departments, community health needs assessment was a new and unfamiliar task for which they had few resources and little training. Resources provided by the state health department included orientation and training programs. Comments on the Committee's Task It was suggested that the public health practices framework applied to local health departments might prove useful to the committee in looking at the performance of a broader range of public and private entities that play a role in protecting and improving a community's health. Discussion by the committee pointed to the importance of state infrastructure for local health department performance and the need to be able to assess state as well as local capacity and performance. In addition, it was emphasized that differences among states in the nature of local health departments can affect which functions can be conducted at the local level and, therefore, their apparent level of "effectiveness." MONITORING AND IMPROVING COMMUNITY HEALTH: A WASHINGTON STATE CASE Study Understanding the political, economic, and social systems that influence the determinants of health will be crucial for the committee's consideration of sets of indicators for performance monitoring. Several workshop presentations explored how one state has been preparing its health system for a role in monitoring community health. In Washington State, a major health reform initiative has led to substantial change in medical care and public health systems. In 1993, passage of the Health Services Act (HSA) authorized universal access to health insurance for all residents through managed competition funded by an employer mandate, individual contributions, and state-subsidized insurance premiums. The HSA also initiated the Public Health Improvement Plan, a biennial blueprint for the future public health system. The plan emphasizes the core functions of public health and population-based prevention rather than acute clinical care for individuals. The first version of the plan, published in 1994, articulated how the public health system would assure accountability for its contribution to health status improvement through a set of system capacity stan-

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Improving Health in the Community: A Role for Performance Monitoring dards and health status outcomes (Washington State Department of Health, 1994). In 1995, the legislature repealed large sections of the 1993 HSA. The new legislation contained some insurance reforms, portions of the previous health data system, and quality improvement initiatives. It increased state-sponsored health care for low income individuals and families and left intact the public health system reforms reflected in the Public Health Improvement Plan. Some activities under way before the legislative changes were emphasizing the value of prevention and the need for partnerships among public, private, and academic health systems. Public Health in Washington State5 Washington's population of about 5 million is served by 33 local health jurisdictions that are independent of the state health department and provide few personal health care services. In the late 1980s, the state reestablished a Department of Health (DOH) separate from the combined Department of Social and Health Services. The broad perspective of public health and the concerns of local health departments had not fit well with the more targeted responsibilities of the various social service programs. The role of the state board of health was reaffirmed, along with its connection to local health departments. The DOH is a principal link between the state government and local health departments, but it also has a broader perspective on health that includes working with other state agencies (e.g., education) and with the private sector to provide for the health of the public. The department is also working with the private sector in developing improved data systems. Two elements of Washington's experience were important for the IOM committee's work. First, the early and continuing emphasis on a systems approach required collaboration across organizational boundaries. Voluntary efforts of this sort can be difficult to sustain. Second, the success of many of the state's activities relied on developing a "shared vision" among many groups for criteria for good health in the state. That vision becomes the basis for assessing public health performance and outcomes. 5   This section is based on a presentation by Kristine Gebbie.

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Improving Health in the Community: A Role for Performance Monitoring Linking Academic Health Centers and Local Health Departments6 The School of Public Health at the University of Washington grew out of the medical school's department of preventive medicine. The school receives limited state support and relies heavily on federal research support and other grants and contracts to fund salaries and other activities. A 1990 grant from the Health Resources and Services Administration supported the creation of a Center for Public Health Practice. The Center's goals are to provide continuing education to public health practitioners, place students in practicum situations, and form linkages between the school and public health practice settings. The Center has responded to training needs in local health departments with a two-week summer institute and, in collaboration with the state DOH, the local public health community, and several university programs, with a series of training modules that are offered via satellite in seven locations throughout the state. Training needs include: assessment techniques, data analysis, and community organizing. In other collaborations, a tenured faculty member serves as health officer for a rural county in central Washington. This arrangement provides a training site for students and establishes a link for the faculty with local health officers. Ties with the state DOH have been strengthened by cross appointments. For example, the state health officer serves as assistant dean for public health practice. The links with public health practitioners are also adding new perspectives to the content of the academic program. Workshop discussion suggested that local and state health departments would benefit from easier access to the technical expertise of academic health centers, particularly in analytic areas such as biostatistics. Private Sector Participation in Community Health Activities: The Role of Group Health Cooperative of Puget Sound7 Group Health Cooperative of Puget Sound (GHC), the nation's largest consumer-governed nonprofit health maintenance organi- 6   This section is based on a presentation by James Gale. 7   This section is based on a presentation by Bill Beery.

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Improving Health in the Community: A Role for Performance Monitoring vision, the committee intends to take significant steps toward its initial specification. A central focus will be to Describe how to use a PHPM system to improve the public's health by identifying the range of actors that can affect community health, monitoring the extent to which their actions make a constructive contribution to the health of the community, and promoting policy development and collaboration between public and private sector entities that are responsible for components of the larger health enterprise of the nation. To further develop its vision for PHPM, the committee aims to Specify an organizational and policy context for public health performance monitoring that unites the interests and authorities of the local, state, and national public and private sector entities that should be held accountable for the public's health; Advance a series of definitions to guide the development of a PHPM system; Document and critique the current state of the art in PHPM; Recommend innovations and priorities in the development of new measurement and data management systems to serve comprehensive PHPM; Provide detailed examples of several recommended performance indicator sets, illustrating the integration of data from multiple sources to assess various dimensions of the state of the public's health in relation to key health problems or risks. These dimensions would include (a) individual health status, (b) behavioral, biological, and environmental risk factors, and (c) the availability and use of individual- and population-focused interventions known to improve health; Recommend a set of performance indicators that would capture information on the most important health problems faced by the population so as to have a monitoring system that will continually assess the health status of the public; Specify recommended characteristics of the structure, resources, and reporting relationships among participants in the PHPM system; provide guidance on how public and private sector entities can work jointly to develop a PHPM system that is of use to the organizations as well as to the public's health; and Identify ways in which such a PHPM system can be continuously refined to accommodate emerging priorities in the nation's health.

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Improving Health in the Community: A Role for Performance Monitoring Background Performance measures have been used in assessing health status, personal health care services, as well as population-based public health activities with increasing sophistication for many years. Today, performance measures are gathered and used by a wide variety of sources: academic researchers, census takers, hospitals, public health and safety agencies, drug companies, insurance companies, employers and other health care purchasers, quality assurers, clinicians, and educators. Uses include resource allocation, monitoring of trends, cost containment, management, quality assurance, and accreditation. In the personal health care area, for instance, HEDIS: The Health Plan Employer Data and Information Set, produced by the National Committee for Quality Assurance, is a defined set of performance measures used by employers and HMOs to compare health plans on the basis of quality, access and patient satisfaction, delivery of preventive services, membership and utilization, financing, and descriptive management information. The Joint Commission on Accreditation of Healthcare Organizations has used standards, the focus of which have in recent years been in keeping with a broader philosophy of performance monitoring. Performance measurement has also been developed in public health. Healthy People 2000: National Health Promotion and Disease Prevention Objectives, produced by the Public Health Service with the collaboration of the Institute of Medicine, outlines 22 categories of measurable health objectives in health status, risk reduction, and services and protection, that is, both process and outcome measures. The objectives process has been implemented by a number of states and local health departments, in some cases using the tools provided by Healthy Communities 2000 and earlier editions of the Model Standards, which is run with American Public Health Association (APHA) coordination. Healthy Communities 2000 helps states and communities adapt Healthy People 2000 objectives to their specific needs and frame the links between health outcomes and public health structure and process. "America's Public Health Report Card," prepared by APHA, and APEXPH: Assessment Protocol for Excellence in Public Health, developed by the National Association of County Health Officials and others, illustrate other approaches. APEXPH, for example, offers local health officers a workbook for conducting an assessment of the strengths and weaknesses of their department. It also provides health departments with guidance on working with oth-

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Improving Health in the Community: A Role for Performance Monitoring ers in the community to assess and respond to community health needs. CDC's Public Health Practice Program Office (PHPPO) is leading efforts to respond to objective 8.14 in Healthy People 2000, which calls for measuring the extent of effective public health practice at the local level. This work derives not only from Healthy People 2000 and Healthy Communities 2000, but also from definitions of public health core functions in the IOM report The Future of Public Health and CDC's earlier work on "public health practices." Taken together, these activities provide a good foundation for monitoring key health outcomes and public health practices. What is needed, and will be the centerpiece of the IOM study, is a way to use the available systems and others to assess how well the providers of population-based core public health services, in conjunction with providers of personal health services, perform and interact in protecting and improving the health of communities. PHPM Examples If public health performance monitoring is to develop into an important tool used by many and varied entities, an ongoing conceptual development process is critical. Each user will face its own decisions, look at a health question from its own vantage-point, and scrutinize particular opportunities to influence the health of the public it serves. Not only will different users have different priorities, they will have different budgets, time frames, and values, all influencing the balance of measures to be chosen. Ongoing changes in emerging technologies in clinical medicine, improving informatics, new biophysical technology, and evolutions in marketing, governance, and benefits coverage, along with redefined values, will compel the PHPM system to anticipate and help shape, as well as respond to, changes in health and health care in the United States. For these reasons, the committee will not offer a full prescriptive set of PHPM indicators, but will develop a framework for such a system and practical examples of its application in about ten critical areas. In its report, the committee will illustrate the process it recommends for the development of a PHPM system, using examples suitable for diverse potential users and situations. Those seeking to use performance monitoring could include local, state, or federal government public health agencies; employers; private health industries; community organizations; budget analysts; accredit-

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Improving Health in the Community: A Role for Performance Monitoring ing organizations; health-related workforce planners and educators; and research agenda setters. Specific community health concerns to be addressed might be selected from broad categories such as environmental toxins, infectious disease, injury control, quality of life in chronic disease, mental illness, and vulnerable populations (such as children, the elderly, and those with financial or geographic access difficulties). Selection of these specific examples will depend on various considerations including the extent to which meaningful health improvements can be promoted by appropriate and measurable actions taken by identifiable parties within a community. The appropriate actions and actors to monitor are likely to vary across communities because of factors such as differences in the organization of the public and private health sectors and in the political, economic, and cultural contexts. For each specific health concern chosen for detailed consideration, the committee will suggest a set of indicators that, taken together, can be used to monitor health status in relation to actions that should have an influence on it. Indicators should be selected so as to promote constructive actions that are expected to have a positive influence on community health. For example, monitoring smoking rates among health plan members might encourage a plan to avoid enrolling smokers rather than to offer smoking cessation programs. The committee also will identify some of the information sources for particular indicators and will address methods for presenting and analyzing that information. An example might be a set of indicators on tobacco and health that can be used to monitor health effects associated with tobacco use and factors that can influence the use of tobacco. The indicators could include elements such as: traditional vital statistics (e.g., lung cancer and heart disease mortality and morbidity rates), results from behavioral risk and attitude surveys, use rates for tobacco and other substances (e.g., excise taxes collected on tobacco products, sales figures, survey data), quit rates, smoking cessation program availability (location, price, enrollment), business policy actions (e.g., advertising budgets and strategies), local government actions (e.g., regulation of tobacco use in public places),

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Improving Health in the Community: A Role for Performance Monitoring youth access to tobacco products, economic costs of tobacco use (e.g., morbidity, mortality, work loss), and the implementation of public and private tobacco control programs. Implementation To achieve its goals, the committee will prepare a book-length report that would introduce a vision of a PHPM system that can monitor and improve the production of health in communities; clarify the vision and its value to stakeholders, including the public; and document the current reality of scientific cultures, political environments, and gaps in knowledge in our current understanding of health and its determinants. The report will recommend guiding principles and who can do what to move us toward the vision. The report will include examples that demonstrate how a PHPM system can be used by a community to characterize and monitor the actions that the agencies, organizations, individuals, and other entities in a community could be expected to take to contribute to health improvement, and to apply the information generated to encourage entities to take those actions that promote improvements in the community's health. These examples will demonstrate tools that communities can use to address other health concerns. Sections in the report (as it is currently planned) will address: The committee's vision, and PHPM definitions and concepts. The current reality of the political and cultural environment in which PHPM must take place, including the need for better links between medical care and public health; differences of language, culture, conflicting goals and interests; many stakeholders with different needs/perceptions; diversity and complexity; and problems with accountability. Health and its biologic and social determinants, including basic questions such as the definition of health and ways to measure it in the determinants of health; the interconnectedness of health, public, and social systems. Health systems, including capacities of well-functioning health systems such as problem identification and monitoring; relations among public health systems, care providers, and so on;

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Improving Health in the Community: A Role for Performance Monitoring capacities for measuring health system effectiveness; well-functioning processes of change and improvement and feedback. Detailed examples, as suggested above, of indicator sets that can be used for public health performance monitoring directed toward specific health concerns. Detailed examples of public health performance monitoring as it currently exists or can exist in particular states or localities; each would focus on the system as a whole, how problems are identified, and how specific problems are managed. Recommendations regarding guiding principles and operationalizing the vision.

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Improving Health in the Community: A Role for Performance Monitoring WORKSHOP AGENDA May 24–25, 1995 Cecil and Ida Green Building 2001 Wisconsin Avenue, N.W. Washington, D.C. Wednesday, May 24, 1995 9:00 a.m. Welcome   Michael Stoto     Director, IOM Division of Health Promotion and Disease Prevention 9:10 a.m. SESSION 1: Workshop Introduction and Goals   Thomas Inui     Professor and Chair, Department of Ambulatory Care and Prevention, Harvard Medical School     Co-Chair, IOM Committee on Public Health Performance Monitoring   Susan Thaul     Study Director, IOM Committee on Public Health Performance Monitoring 9:40 a.m. SESSION II: Connecting with the Community   Facilitator: Thomas Inui   Richard Garfield     Professor, Columbia University School of Nursing   Shoshanna Sofaer     Associate Professor, George Washington University Member, IOM Committee on Public Health Performance Monitoring 11:00 a.m. SESSION III: Public Health Practice and Process Measurement in the Community   Bernard Turnock     Clinical Professor of Community Health Sciences, University of Illinois at Chicago 12:00 p.m. Lunch

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Improving Health in the Community: A Role for Performance Monitoring 1:00 p.m. SESSION IV: Public Health Performance Monitoring: A Case Study from the State of Washington   Introduction and Facilitator: Bobbie Berkowitz     Deputy Secretary, Washington Department of Health Co-Chair, IOM Committee on Public Health Performance Monitoring 1:15 p.m. Overview   Kristine Gebbie   Faculty, Columbia University School of Nursing   Former Commissioner of Health, Washington   Member, IOM Board on Health Promotion and Disease Prevention 1:30 p.m. Academic Health and Local Health Departments   James Gale   Professor, University of Washington School of Public Health, Health Officer, Kittitas County Washington   Member, IOM Committee on Public Health Performance Monitoring 1:50 p.m. Public-Private Cooperation for Health Improvement Activities   Bill Beery   Director, Center for Health Promotion, Group Health Cooperative of Puget Sound 2:20 p.m. Environmental Risk Assessment and Data at Local Health Departments   Carl Osaki   Director, Environmental Health, Seattle-King County Department of Health 2:40 p.m. Data Systems/Quality   Elizabeth Ward   Assistant Secretary, Epidemiology and Health Statistics, Washington Department of Health 3:25 p.m. Community Health Assessment and Information Use by Local Health Departments   James Krieger   Chief of Epidemiology, Planning, and Evaluation, Seattle-King County Department of Health 4:25 p.m. Discussion 5:00 p.m. Summary Comments   Alan Cross   Director, Center for Health Promotion and Disease Prevention, University of North Carolina   Vice Chair, IOM Committee on Public Health Performance Monitoring 6:00 p.m. Adjourn

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Improving Health in the Community: A Role for Performance Monitoring Thursday, May 25, 1995 9:00 a.m. SESSION V: Revisit Yesterday's Discussion and Broaden Scope   Facilitator: Thomas Inui 10:00 a.m. SESSION VI: National Activities: Other Involvement with Performance Monitoring and Reaction to Committee Draft Vision   Facilitator: Alan Cross   Linda Demlo     Acting Director, Center for Quality Measurement and Improvement, Agency for Health Care Policy and Research   Randy Gordon     Associate Director for Managed Care, Centers for Disease Control and Prevention   Claude Hall     Director, Model Standards Project, American Public Health Association   Roz Lasker     Deputy Assistant Secretary for Health Policy Development, Office of the Assistant Secretary for Health   Nancy Rawding     Executive Director, National Association of County and City Health Officials   Cary Sennett     Vice President, National Committee for Quality Assurance   Margaret VanAmringe     Washington Office Director, Joint Commission on Accreditation of Healthcare Organizations   Ronald Wilson     Special Assistant, Office of Analysis, Epidemiology, and Health Promotion, National Center for Health Statistics 12:00 p.m. Committee Challenge, Wrap Up and Thank You   Facilitator: Bobbie Berkowitz 12:30 p.m. Adjourn

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Improving Health in the Community: A Role for Performance Monitoring WORKSHOP SPEAKERS AND GUESTS Speakers BILL BEERY, Director, Center for Health Promotion, Group Health Cooperative of Puget Sound, Seattle, Washington LINDA DEMLO, Acting Director, Center for Quality Measurement and Improvement, Agency for Health Care Policy and Research, Rockville, Maryland RICHARD GARFIELD, Professor, Columbia University School of Nursing, New York, New York RANDOLPH GORDON, Associate Director for Managed Care, Public Health Practice Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia CLAUDE HALL, JR., Director, Model Standards Project, American Public Health Association, Washington, D.C. JAMES KRIEGER, Chief of Epidemiology, Planning, and Evaluation, Seattle-King County Department of Health, Seattle, Washington ROZ LASKER, Deputy Assistant Secretary for Health Policy Development, Office of the Assistant Secretary of Health, Department of Health and Human Services, Washington, D.C. CARL OSAKI, Director, Environmental Health, Seattle-King County Department of Health, Seattle, Washington NANCY RAWDING, Executive Director, National Association of County and City Health Officials, Washington, D.C. CARY SENNETT, Vice President for Planning and Development, National Committee for Quality Assurance, Washington, D.C. BERNARD TURNOCK, Clinical Professor of Community Health Sciences, University of Illinois at Chicago MARGARET VANAMRINGE, Director of the Washington Office, Joint Commission on Accreditation of Healthcare Organizations, Washington, D.C. ELIZABETH WARD, Assistant Secretary, Epidemiology and Health Statistics, Washington State Department of Health, Olympia, Washington RONALD WILSON, Special Assistant, Office of Analysis, Epidemiology and Health Promotion, National Center for Health Statistics, Hyattsville, Maryland Invited Guests CYNTHIA ABEL, Program Officer, Division of Health Promotion and Disease Prevention, Institute of Medicine, Washington, D.C. MIKE BARRY, Project Manager, Public Health Foundation, Washington, D.C.

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Improving Health in the Community: A Role for Performance Monitoring CHERYL BEVERSDORF, Executive Vice President, Association of State and Territorial Health Officials, Washington, D.C. JUDITH MILLER JONES, Director, National Health Policy Forum, Washington, D.C. NANCY KAUFMAN, Vice President, The Robert Wood Johnson Foundation, Princeton, New Jersey JORDAN RICHLAND, Executive Director, Partnership for Prevention, Washington, D.C. JOSEPH THOMPSON, Luther Terry Fellow, Office of Disease Prevention and Health Promotion, U.S. Public Health Service, Washington, D.C. ALISON WOJICIAK, Manager of Practice Programs, Association of Schools of Public Health, Washington, D.C.