National Academies Press: OpenBook

Improving Health in the Community: A Role for Performance Monitoring (1997)

Chapter: C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)

« Previous: B Methodological Issues in Developing Community Health Profiles and Performance Indicator Sets Michael A. Stoto
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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).

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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-

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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-

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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-

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

zation (HMO), was established in 1947 and has about 540,000 enrollees. GHC has an active program of performance monitoring that serves a variety of purposes, including HEDIS reporting to employers on health plan performance; accreditation requirements; data for an internal quality initiative; and feedback to individual clinicians. Performance measures are developed based on sources such as GHC's strategic plan and periodic vision statements. Eleven prevention and health promotion performance priorities have been specified.8

GHC has adopted a set of community service principles and a vision statement that calls for delivery of quality health care to the entire community, not just its enrolled population. Health promotion and disease prevention activities are currently focused on four areas: childhood immunization, the reduction of infant mortality, health care for homeless families, and the reduction and prevention of interpersonal violence. Several factors were considered in undertaking community programs. Improved community health is expected to lead to improved health for members. In some cases, members—or future members—may benefit as part of the target audience for specific programs. Some health problems (e.g., violence, alcohol abuse) require community-based programs because they are not easily addressed in a medical care framework. Community-based programs enhance GHC's competitive position for contracts with large employers and for services to Medicaid and Medicare populations. They also help fulfill community benefit obligations to maintain nonprofit status. Altruism is part of the motivation for these activities but will not outweigh long-term financial considerations.

Evaluating the impact of GHC's programs on community health and assessing costs and benefits for the organization will be challenging. GHC faces competition for resources within the organization, which creates pressures to focus exclusively on members' health care needs. No consensus exists on the extent of a health care organization's responsibilities in areas often considered "public health," and it may be difficult to sustain community efforts unless other health care organizations accept similar responsibilities, including public reporting on the extent to which

8  

The 11 prevention priorities are tobacco use, alcohol consumption and abuse, depression, cancer, high-fat diet, inactivity, diabetes, immunization and infectious disease, HIV/AIDS, heart disease, and injuries.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

their efforts are meeting expectations. Communities may be able to promote an expectation for health plan participation.

Performance monitoring presents an opportunity to assess individual health care organizations and to encourage efforts such as health promotion rather than care for preventable illness. It may also be possible to monitor health plan partnerships with local health departments and other community groups. Some organizations (e.g., health plans, employers) may see their link to community service more readily than to public health.

The committee's vision statement was seen as an appropriate challenge for all health plans. Performance monitoring will, however, require developing explicit expectations in several areas: responsibilities of medical care organizations; public-private partnerships; contributions to community capacity-building; collaboration in community programs; how to monitor the extent to which partnerships exist; and the appropriate role of the consumer (individuals, groups, or the community).

The discussion highlighted concern that performance measures will focus attention on some tasks to the exclusion of others. Therefore, the selection of measures is a critical process that must be carefully and openly considered so that the implications of those selections are understood. Also noted was concern that measurement tasks are viewed very narrowly. Individual organizations may not be able to sustain more expansive approaches if competing groups do not make a similar effort.

Addressing Environmental Health Issues9

Although there are important links between environmental health issues and public health, some environmental health agencies have seen themselves as having separate responsibilities from what are perceived as personal health issues. The resulting organizational distance between the two fields has left many environmental health professionals out of the discussions about new approaches to public health practice and without an appreciation of their role in public health systems. Environmental health needs to develop new approaches to data collection and analysis that demonstrate the links between environmental health functions

9  

This section is based on a presentation by Carl Osaki.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

and good health outcomes. In Seattle-King County, the focus has been on process measures (e.g., numbers of restaurant inspections conducted) without knowing the extent to which those activities contribute to disease prevention.

In Washington State, efforts are being made to bring environmental health clearly into the realm of public health. Environmental health directors in the state are working to develop clear and comparable definitions of terms and to address how to collect information that can be useful in efforts to improve community health status. An environmental health addendum has been developed for APEXPH materials for community assessments (Washington State Department of Health, 1993). A new model for the links between a community's health and environmental factors is emerging. This approach looks at health outcomes at the intersection of a population at risk, unsafe behavior, and an environmental hazard.10 Each component of the model seems to have measurable elements that might guide preventive efforts to avert their intersection and an adverse health outcome.

The workshop participants saw how the model's concepts might apply beyond the traditional bounds of environmental health. Many thought, however, that the term "unsafe behavior" could be misunderstood as referring only to the behavior of the population at risk rather than to actions by a broad range of parties. Developing useful performance standards for environmental health will require further work to ensure that actions being measured have an impact on health. An important aim is to focus attention on issues beyond environmental hazards. It was emphasized that community-based assessments need approaches to performance monitoring that can link all of the determinants of a community's health, including the environmental and personal health care perspectives.

10  

Since the workshop, there has been further refinement of the model, influenced in part by comments offered at the workshop. It bases an assessment of health status on the interaction of environmental hazard(s), population(s) at risk, and public health protection factors. The model demonstrates the need to consider more factors than the regulation of hazards and to take a broad community perspective. The revised model has been endorsed by directors of environmental health in Washington State's local health departments and by the state Department of Health.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
A Voluntary Approach to Public—Private Health Information Systems11

As part of its 1993 health care reform program, Washington State mandated creation of a statewide health data system to monitor and evaluate the effectiveness of reform efforts. Subsequently, the state has stepped back from the original mandates to adopt a more voluntary approach to health care reform. Health data system issues are now being addressed through a public-private partnership facilitated by the state. The change has overcome some of the resistance to a state-run system and may promote progress.

The state DOH has retained responsibility for considering data standards and quality improvement efforts. Several groups have been formed to address specific areas such as patient care, health status, and community assessment. Collaboration among the groups working on data on patient care, community assessment, health status, and enrollee measures has produced a proposal for a "clinical outcome measure amended HEDIS" strategy (COMAH). It combines clinical outcome measures with the more process-oriented HEDIS measures; only a few measures in this set will be community based. Data collection will be tested in a variety of settings including physicians' offices. These measures reflect the interests of the participating groups but not externally established or coordinated criteria for an appropriate or complete set of indicators. Other groups will be producing proposals that focus more on community health measures.

Communication between participants with a personal health care perspective and those with a public health perspective has made health care providers more interested in having access to population-based and clinical data. For community-oriented health plans such as GHC, Washington's collaborative approach to data systems development may offer a way to receive public recognition for some of their activities and to influence other health plans. Washington's experience with a voluntary public-private approach to developing data systems may be a useful reality check for the committee on the information health plans are willing to share.

11  

This section is based on a presentation by Elizabeth Ward.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Community Health Assessment in Seattle—King County12

The Seattle-King County health department's community health assessment program offers insights into the process of monitoring performance to improve the community's health. The program produces information on the community's major health problems and strengths, on perceptions about health-related concerns, and on health services. The results guide and motivate the development of policies and interventions, including action by community groups. The assessment program is a process, not just publishing a report. Data are reviewed with the community and with decision makers to understand whether the results seem reasonable, whether there are gaps between findings and perceptions, and whether there are concerns that have not been included. The review also identifies areas of special interest to the community and generates guidance on how to treat sensitive issues. In Seattle-King County, health department reports are released only after this kind of consultation.

Assessment Domains

The domains of the assessment process include health status, risk factors and other determinants of health, and health interventions. Standard measures are not available for social factors affecting health. Variables such as income, education, and race often serve as proxies. Other factors for which better measures are needed include stress, social support, and community values. In monitoring community health interventions, information is needed on the nature of the interventions, the targeted recipients (e.g., specific individuals, subpopulations, or the entire community), and providers (e.g., public health agencies, employers, schools). For many interventions, however, monitoring is hindered by limited evidence on their effectiveness.

Data Sources

In Seattle-King County, data for assessments come from sources such as vital statistics, hospital discharges, environmental inspections, and crime reports. No data are routinely available

12  

This section is based on a presentation by James Krieger.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

on outpatient or emergency department care. Use of cancer registries is beginning. Some environmental data can be difficult to obtain in sufficient geographic detail for county analysis. Local surveys are used, but resources are not available to cover all areas of interest. Expanding the size of samples in state surveys, oversampling of some populations, or collecting additional information on residence could make state data more useful. Special studies, such as hospital record reviews, are used to obtain data on some health problems. Focus groups and selective interviews provide qualitative information to complement quantitative data. The value of combining data from multiple sources and making the best use of available data sources was emphasized.

Some recurring technical concerns related to the lack of clear standards for data and analysis were noted. Problem areas include classifying race and social status and inconsistent age-adjustment practices. Also mentioned were differences in diagnostic coding and in practices followed in statistical testing.

Populations of Interest

The health department has defined its population of interest on the basis of residence. Analyses of subgroups within the population are frequently valuable and require information on characteristics such as age, gender, race and ethnicity, educational attainment, and income. Experience has shown that "local" data on the county's 21 health planning areas generate greater interest and impact than countywide data. Determining the size of the denominator population, and relevant subpopulations, is an important and challenging task at the community level. Census data are supplemented with intercensal estimates from state and local agencies and from commercial vendors. Local health departments might benefit from access to additional expertise in making such estimates.

Selecting Indicators

Specific indicators used in the Seattle-King County assessment process reflect input from sources such as the statewide Community Data Task Force, various constituencies within the county, and the county health department. Factors considered in selecting indicators include the incidence or prevalence and the severity of a condition. The perceived importance in the community and likely community response are also considered. Other

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

factors include the cost and availability of data and consistency with indicators used elsewhere (e.g., Healthy People 2000 [USDHHS, 1991]).

Using Assessment Data

Information generated by the Seattle-King County health assessment program is being used for establishing priorities for health interventions and allocating state funds from the Public Health Improvement Plan. The assessments are also providing information needed to target interventions and are guiding program and policy development. County assessment data are used for comparisons with state and national data as well.

Some of the assessments that health agencies would like to make are complicated by resistance within the community due to the sensitive nature of some topics (e.g., data on sexual activity among teenagers). A suggestion at the workshop that health plans and other health care providers might be an alternative source of similar information brought the observation that sensitive information may be difficult to collect in that setting as well.

Promoting Community Participation

Seattle-King County has found that coalitions of community stakeholders (e.g., public health agencies, health plans, employers) need to be developed early in the assessment process. Such groups can provide valuable guidance on selecting indicators, interpreting assessment results, and understanding their policy implications. Public meetings that include community leaders can involve a broader segment of the community in health assessment and planning. Participation promotes community ''ownership" of the process and the results.

Health departments are generally a resource for essential technical and organizational services for community health assessment. They can provide expertise and computing facilities needed to frame some indicators and to perform data management and analysis tasks. They can also help build community coalitions.

It was noted that health plans can be a source of information about their members and should be able to benefit from knowing more about the factors affecting health in the community. Their collaboration in community health assessment may encourage, and be encouraged by, the development of common goals for member and community health. Establishing common community

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

practices in data standards and data interchange might promote health plan participation.

Observations to the Committee

Final remarks in this presentation highlighted several issues in monitoring community health. Monitoring needs to be a dynamic process and should promote local involvement. Indicators used for monitoring need to focus on risk factors with interventions known to be effective. Research is needed, however, to establish the effectiveness of a much broader range of interventions. Indicators should address not only health risk factors but also factors that promote good outcomes.

Some specific areas in which the committee might be helpful were noted: proposing indicators; encouraging the development of indicators for less developed domains such as environmental or social determinants of health; suggesting data standards for defining populations; and outlining processes for involving community stakeholders.

ACTIVITIES AT THE NATIONAL LEVEL

A variety of federal agencies and private sector organizations have programs that address monitoring and improving community health. The workshop gave the committee an opportunity to learn more about the work being done by some of these groups.

Federal Agencies
Office of the Assistant Secretary for Health13,14

The Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services (DHHS) has had broad responsibilities and interests in both health care and public health. Three activities have special relevance for the committee's work: (1) proposed performance partnership grants to states, (2) public health participation in the National Information Infrastruc-

13  

This section is based on a presentation by Roz Lasker.

14  

Following the workshop, a reorganization in the U.S. Department of Health and Human Services placed the activities described in this section under the direction of the Office of the Assistant Secretary for Planning and Evaluation.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

ture (NII) initiative, and (3) development of comprehensive information on the nation's public health infrastructure.

Performance partnership grants Performance partnership grants (PPGs), are intended to combine the specificity and accountability of categorical programs with the flexibility of block grants. They are proposed for six areas: mental health, substance abuse, HIV/STD/TB, chronic diseases and prevention of disabilities, immunizations, and preventive health and health services. For each area, states would reach an agreement with DHHS on specific targets for improvement and the degree of improvement sought. Grants would provide states with funding for 3 to 5 years to achieve specific and measurable health status improvements.

A menu of health status objectives from which states can choose is to be developed in a collaborative effort organized by DHHS. Several factors will be considered in selecting PPG objectives: links to Healthy People 2000 (USDHHS, 1991); issues that are important and understandable to policymakers and the public; aspects of health status on which states can be expected to have an impact and for which change can be measured during the grant period; clearly specified measures; and timely availability of comparable data of good quality at a reasonable cost.

National Information Infrastructure Another important activity is bringing public health interests into the NII initiative, which is promoting the enhancement of the nation's computing and telecommunications infrastructure (see Lasker et al., 1995). Public health professionals are bringing to these discussions a familiarity with and interest in data issues that have not always been found in work with the health care community. Through its participation in the NII initiative, the public health community is gaining knowledge of and access to computing resources.

Information on the public health infrastructure The lack of, and need for, comprehensive information on the nation's public health infrastructure became clear during the development of health care reform proposals in 1993 and 1994. DHHS is funding a project to assemble a database on public health resources at the national, state, and local levels. This effort will include bringing together individuals and organizations already looking at these issues to develop a consensus on definitions and typologies for the elements of such a database.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Agency for Health Care Policy and Research15

The primary activities of the Agency for Health Care Policy and Research (AHCPR) relevant to performance monitoring include the development of clinical practice guidelines, technology assessment, support for outcomes research, and applied research on health care quality measurement and improvement.

One relevant project is collecting and classifying clinical performance measures being used by health care providers in the public and private sectors (Center for Health Policy Studies and Center for Quality of Care Research and Education, 1995). This "typology project" is producing a database with information on about 1,300 individual measures found in 40 measurement systems. The database will allow users to explore specific measures within the project's classification system and to identify measures linked to specific clinical conditions or patient populations. Anther project was aimed at producing information that can help consumers choose among health plans (Research Triangle Institute, 1995). It focused on developing questionnaires that could be used to collect information from and for health care consumers. Specific areas of attention include access to care, use of services, health outcomes, and satisfaction with care. The Consumer Assessment of Health Plans Study is following up the initial work.

Centers for Disease Control and Prevention: Activities in Managed Care16

Public health agencies have generally been responsible for broad community health needs but in many communities have also been providing personal health services. In the private sector, the growth of managed care organizations (MCOs) is shifting attention from individual patients to entire enrolled populations, including groups formerly served by public health agencies. The Centers for Disease Control and Prevention (CDC), guided by a Managed Care Working Group, is examining its role in this changing health care environment.

CDC is encouraging MCOs and other private sector health care providers, in collaboration with public health agencies, to

15  

This section is based on a presentation by Linda Demlo.

16  

This section is based on a presentation by Randolph Gordon.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

give greater attention to prevention and community health. Concerns about the profitability of those activities may, however, encourage private sector health care organizations to focus their attention on their enrolled populations. There is need to create a new view of prevention as an investment in the quality of health services and not simply a means of avoiding treatment costs.

Among CDC's priorities is an effort to identify effective forms of community-based prevention and compile a guide to those interventions (similar to the report of the Clinical Preventive Services Task Force). CDC is also encouraging greater participation by state health agencies in the development and implementation of Medicaid Managed Care waiver programs. Another CDC priority is to enhance MCO contributions to public health activities and community health planning.

National Center for Health Statistics17

The National Center for Health Statistics (NCHS), a component of CDC, collects and reports national, state, and local health data. In addition to its role in assembling vital statistics data and conducting several long-standing surveys such as the National Health Interview Survey, NCHS has major responsibilities associated with Healthy People 2000 (USDHHS, 1991). A particular focus is the set of 18 health status indicators selected in response to Healthy People 2000 Objective 22.1, which calls for "a set of health status indicators appropriate for Federal, State, and local health agencies," and the summary indicator of years of healthy life (CDC, 1991; Erickson et al., 1995). A recent report prepared for NCHS compiled information on several sets of health care indicators, some of which are currently in use (see Lewin-VHI, 1995).

Among the points emphasized was making a careful assessment of data needed for performance monitoring. The cost of data collection could become a constraint as could the burden on those providing the data. Collecting some data less frequently or from a more limited population may be adequate. Also emphasized was the need to determine whether changes in health-related indicators signal real changes in health status.

17  

This section is based on a presentation by Ronald Wilson.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Private Sector Organizations
American Public Health Association18

Healthy Communities 2000: Model Standards (APHA et al., 1991) is a tool designed to help communities and local public health agencies monitor and improve health by translating the national health promotion and disease prevention objectives of Healthy People 2000 into local objectives and developing community action plans to achieve those objectives. Use of Model Standards in conjunction with APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991) has been encouraged. In contrast to earlier versions, Healthy Communities 2000 has built more directly on the national objectives of Healthy People 2000 to provide an explicit link from the national level to state and local efforts. It also has expanded on some areas, such as environmental health, that received limited attention in Healthy People 2000.

Several suggestions about performance monitoring were offered to the committee. The recent collaboration among major businesses to negotiate with managed care organizations illustrates the diversity of perspectives on "community" health and the complexities in identifying relevant stakeholders for health improvement efforts (residents, enrollees, purchasers/employers, providers). Also stressed was seeing performance measures as part of a larger picture that includes other tools, such as practice guidelines and model standards, that can help guide community decision making.

National Association of County and City Health Officials19

The National Association of County and City Health Officials (NACCHO) is responsible for producing APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991). This workbook for local health officers has two parts. Part one is an organizational capacity assessment to identify strengths and weaknesses in a health department and develop a responsive action plan. The second part guides health departments in developing a community health planning committee that can identify health problems of concern to the community and mobilize the community to ad-

18  

This section is based on a presentation by Claude Hall.

19  

This section is based on a presentation by Nancy Rawding.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

dress them. Also available is APEXPH in Practice (NACCHO, 1995a), which provides tools to facilitate use of APEXPH.

NACCHO recently published a profile of local health departments that presents, in the aggregate, information on their organization, resources, and activities (NACCHO, 1995b). NACCHO also plans to revise APEXPH , including enhancing the limited environmental health component.20 NACCHO also is working through the Joint Council of Governmental Public Health Agencies on the role of state and local public health departments in issues of quality assurance and accountability as they affect population groups. Previously NACCHO collaborated with CDC to produce Blueprint for a Healthy Community (NACHO and CDC, 1994), which outlines 10 elements needed to protect and promote community health.

National Committee for Quality Assurance21

The National Committee for Quality Assurance (NCQA) focuses on quality in health care and on providing purchasers and consumers of health care services with information that helps them select among health plans offering those services. It uses accreditation to establish that health plans have structures and processes that should enable them to meet the needs of their enrolled populations.

NCQA has three aims for performance measurement. First, there should be national standardization of measures. Second, application of those measurement standards should be documented. Third, performance measurement should produce information that promotes quality improvement. NCQA is addressing these aims with HEDIS—the Health Plan Employer Data and Information Set—which provides a standard set of measures that helps purchasers compare health plans and helps health plans assess their own performance (NCQA, 1993).

NCQA is working with many health plans to help them improve their data collection and analysis capabilities for both external reporting and internal assessment. A pilot project involving 21 health plans with varying characteristics has demonstrated the feasibility of producing "report cards" but also has shown that the process is not easy. Work is also beginning on the HEDIS 3.0

20  

Since the workshop was held, a NACCHO committee has started this work.

21  

This section is based on a presentation by Cary Sennett.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

update. Workshop participants expressed interest in the possibility that HEDIS could be expanded or adapted to meet community health information needs in addition to those of health plans and employers/purchasers. It was suggested that health plans could be gathering more information relevant to community health than they are currently asked to do, but NCQA questions the extent to which HEDIS and health plans should be expected to collect community health data.

Joint Commission on Accreditation of Healthcare Organizations22

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) assesses the qualifications and performance of hospitals and other types of health care facilities. Performance indicators are not considered sufficient by themselves since they can provide only an after-the-fact report.

The Joint Commission is developing preventive services standards, which extends the scope of the continuum of care beyond JCAHO's traditional focus on diagnosis and treatment. Primary, secondary, and tertiary prevention services are all within the scope of the new standards. These standards call for health networks to provide preventive services that are appropriate for their mission, that are considered efficacious, that are appropriate to the needs of the population they serve, and that are provided in an effective manner.

JCAHO also is addressing the development of indicators to monitor how well performance conforms with Joint Commission standards and to provide health care organizations with information needed for quality improvement efforts. The Indicator Measurement System (IM System), originally developed for hospitals, is being expanded to include other kinds of health care organizations and a broader range of indicators covering issues such as access to and satisfaction with care as well as clinical quality of care.

Rather than develop all additional indicators de novo, JCAHO will adopt some that are already available from other sources to address areas of care including substance abuse, mental health, cancer, diabetes, and pregnancy. Of about 800 indicators received from 24 organizations, about half are being evaluated for

22  

This section is based on a presentation by Margaret VanAmringe.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

inclusion in the IM System for managed care networks. JCAHO also hopes to collaborate with other groups to assemble a collection of other indicator systems from which health care organizations can choose.

COMMITTEE COMMENTS ON PRESENTATIONS AND DISCUSSION

The workshop discussions made a valuable contribution to the committee's thinking about the general concept of health-related performance monitoring and about the specific tasks to be addressed in this study. They helped demonstrate the complexity of the issues and the need for further examination of many of the elements of the committee's vision for a performance monitoring system that can promote improvements in community health.

A phrase taken from the statement of the committee's aims, "examine public health performance monitoring from a systems perspective," contains several key terms requiring clarification. "Public" should be understood to mean the general population, the inclusive denominator for the measurement process. For some measures, the population of interest may vary but should be defined as comprehensively as possible. Addressing "health" raises concerns about boundaries on the continuum that ranges from obviously relevant morbidity and mortality to more complex issues of functional status and social constructs of well-being. A distinction must also be made between an individual's health and population-based health.

Trying to understand "performance" leads to questions about how to link it to either resource inputs or health outcomes. "Monitoring" emerges as an ongoing process of collecting, reviewing, and refining information. Finally, a "systems perspective" suggests looking for a way to see the constructive connections that could exist among activities and organizations.

Workshop discussions pointed to important issues that need further attention. The need to strengthen the evidence base for the health benefit—the efficacy—of many population-based health activities is of particular concern. It may not be possible, however, to identify "the" proper response to some health problems because circumstances and acceptable responses vary across communities. The concept of community will require further elaboration as well. Issues needing attention include determining who the community actors are or should be, understanding how they

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

might be expected to change, and identifying strategies that can be used to promote change in a specific community.

The workshop also gave the committee an opportunity to learn about a substantial and diverse array of activities related to performance monitoring that are already in operation. A clear gap exists between the current outcomes and performance measurement work being done in many areas of medical care and that being done for various aspects of public health. Health-related data gathering and analysis activities in many communities are generally not integrated into a coherent system of sufficient quality and scope to support performance monitoring. The committee will have to consider not only the intellectual task of understanding the pieces that make up a performance monitoring system but also the practical realities of the organizational, social, and political context in which such a system will function. The committee will need to understand who the stakeholders are, what concerns they have, and how to promote their collaboration and commitment to making a system work. Within a community, the relationships may be complex: the organizational entity assuring that data are gathered may be different from the entity analyzing the data, which in turn may be different from the entity that has responsibility for developing or implementing changes.

In proposing how a performance monitoring system might work, the committee must take into account the political, economic, and organizational differences among states and communities. The committee's task is complicated further by the important changes occurring in the organization and delivery of public health and health care services. On some issues, such as improving linkages among health sectors and with areas outside the traditional scope of health (e.g., criminal justice, education, housing), the presentations suggested that opportunities exist but that progress has been limited so far.

Of concern to the committee is understanding how to achieve change in communities. What creates "readiness" or incentives to make the changes that address health problems in a collaborative way? What "levers" are available to promote constructive change at the federal, state, and local levels and in public and private sector organizations? The committee also faces the question of how a performance monitoring system fits into a process of community change. Data from a performance monitoring system may promote change, but change may be needed to create a setting in which a performance monitoring system can operate. Because performance monitoring systems will exist in an environment

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

characterized by change, another question emerges for the committee to consider: What kind of system will be able to function successfully now and also be able to adapt to new circumstances?

The committee needs to consider what principles can serve as a guide toward its vision of a performance monitoring system and what some of the practical steps are that could be taken to move toward achieving that vision. The presentations making up the Washington State case study illustrated some of the possible accomplishments at the state and local levels and pointed out some of the obstacles that exist. The diversity of circumstances evident in the workshop presentations means that there will, of necessity, be different approaches to performance monitoring in different places.

As a result of the discussions during the workshop, the committee recognized the critical importance of presenting its ideas in a way that makes them understandable to the variety of audiences that need to participate in efforts to improve community health. A particular concern is ensuring that the phrase ''public health" is understood in its broadest sense. As one step toward greater clarity, the committee changed the name of the study from "Public Health Performance Monitoring" to "Using Performance Monitoring to Improve Community Health."

REFERENCES

APHA (American Public Health Association), Association of Schools of Public Health, Association of State and Territorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, Department of Health and Human Services, Public Health Service, Centers for Disease Control. 1991. Healthy Communities 2000: Model Standards. 3rd ed. Washington, D.C.: APHA.


CDC (Centers for Disease Control and Prevention). 1991. Consensus Set of Health Status Indicators for the General Assessment of Community Health Status—United States. Morbidity and Mortality Weekly Report 40:449–451.

Center for the Advancement of Health and Western Consortium for Public Health. 1995. Performance Indicators: An Overview of Private Sector, State, and Federal Efforts to Assess and Document the Characteristics, Performance, and Value of Health Care Delivery. Washington, D.C.: Center for the Advancement of Health.

Center for Health Policy Studies and Center for Quality of Care Research and Education. 1995. Understanding and Choosing Clinical Performance Measures for Quality Improvement: Development of a Typology. AHCPR Pub. No. 95-N001. Columbia, Md.: Center for Health Policy Studies.


Erickson, P., Wilson, R., and Shannon, I. 1995. Years of Healthy Life. Healthy People 2000: Statistical Notes, No. 7. April. Hyattsville, Md.: National Center for Health Statistics.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

Garfield, R.M., and Abramson, D.M., eds. 1994. Washington Heights/Inwood: The Health of a Community. New York: Health of the Public Program, Columbia University.


IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, D.C.: National Academy Press.


Lasker, R.D., Humphreys, B.L., and Braithwaite, W.R. 1995. Making a Powerful Connection: The Health of the Public and the National Information Infrastructure. Public Health Data Policy Coordinating Committee. Mimeo. Washington, D.C.: U.S. Public Health Service.

Lewin-VHI, Inc. 1995. Key Monitoring Indicators of the Nation's Health and Health Care and Their Support by NCHS Data Systems. Fairfax, Va.: Lewin-VHI.


Miller, C.A., Moore, K.S., Richards, T.B., and McKaig, C. 1994a. A Screening Survey to Assess Local Public Health Performance. Public Health Reports 109:659–664.

Miller, C.A., Moore, K.S., Richards, T.B., and Monk, J.D. 1994b. A Proposed Method for Assessing the Performance of Local Public Health Functions and Practices. American Journal of Public Health 84:1743–1749.


NACCHO (National Association of County and City Health Officials). 1995a. APEXPH in Practice. Washington, D.C.: NACCHO.

NACCHO. 1995b. 1992–1993 National Profile of Local Health Departments . Washington, D.C.: NACCHO.

NACHO (National Association of County Health Officials). 1991. APEXPH: Assessment Protocol for Excellence in Public Health. Washington, D.C.: NACHO.

NACHO and CDC. 1994. Blueprint for a Healthy Community: A Guide for Local Health Departments. Washington, D.C.: NACHO.

NCQA (National Committee for Quality Assurance). 1993. Health Plan Employer Data and Information Set and User's Manual, Version 2.0 (HEDIS 2.0). Washington, D.C.: NCQA.


Research Triangle Institute. 1995. Design of a Survey to Monitor Consumers' Access to Care, Use of Health Services, Health Outcomes, and Patient Satisfaction. AHCPR Pub. No. 95-N003. Cary, N.C.: Research Triangle Institute.


Sofaer, S. 1995. Performance Indicators: A Commentary from the Perspective of an Expanded View of Health. Washington, D.C.: Center for the Advancement of Health.

Studnicki, J., Steverson, B., Blais, H.N., Goley, E., Richards, T.B., and Thornton, J.N. 1994. Analyzing Organizational Practices in Local Health Departments. Public Health Reports 109:485–490.


Turnock, B.J., Handler, A., Dyal, W.W., et al. 1994a. Implementing and Assessing Organizational Practices in Local Health Departments. Public Health Reports 109:478–484.

Turnock, B.J., Handler, A., Hall, W., Potsic, S., Nalluri, R., and Vaughn, E.H. 1994b. Local Health Department Effectiveness in Addressing the Core Functions of Public Health. Public Health Reports 109:653–658.

Turnock, B.J., Handler A., Hall W., Lenihan D.P., and Vaughn E. 1995. Capacity Building Influences on Illinois Local Health Departments. Journal of Public Health Management and Practice 1:50–58.


USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

Washington State Department of Health. 1993. Environmental Health Summary and Background: APEX/PH Grant Environmental Health Addendum . Olympia: Washington State Department of Health.

Washington State Department of Health. 1994. Public Health Improvement Plan. Olympia: Washington State Department of Health.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

COMMITTEE VISION STATEMENT AUGUST 1, 1995

The Institute of Medicine (IOM) Committee on Using Performance Monitoring to Improve Community Health intends to consider, from a systems perspective, the roles that the public health and personal health care systems and other stakeholders play in influencing community-wide health, how their performance of those roles can be monitored, and how a "public health performance monitoring" (PHPM) system can be used to foster collaboration among these sectors and promote improvements in community health. The committee's goal is to develop prototypical sets of indicators for specific public health concerns that communities can use to monitor the performance of public health agencies, personal health care organizations, and other entities with a stake in these matters. The committee will collect and analyze information on existing and planned systems related to public health performance monitoring, confer with experts in the field individually and through workshops, and prepare a written report that sets out principles of public health performance monitoring from a systems perspective, and illustrates these principles in a practical manner.

For PHPM to serve the core functions of public health—assessment, policy, and assurance—the committee foresees a need for an infrastructure for public health information. This information infrastructure would need to monitor diverse phenomena in the many sectors that contribute to the health of populations, including clinical care, environmental services, individual and public education, community social services, and public policy promoting behavioral change, among others. It also would need to employ measurement strategies far more sophisticated than those in current use; provide information on the health status of a community, including threats to its future health; inform decisions about how to improve the health of the public; and document change in community health and in performance of health-related functions. In such a PHPM system, individuals and programs concerned with the health of the public could coordinate data collection, trend and subgroup analyses, decision support, and program evaluation, successfully serving many organizational entities.

To guide its deliberations, the committee has framed an initial vision for PHPM. To affirm the potential future reality of this

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
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-

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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-

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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),

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
  • 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;

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
  • 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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
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

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×

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.

Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 374
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 375
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 376
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 377
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 378
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 379
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 380
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 381
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 382
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 383
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 384
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 385
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 386
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 387
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 388
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 389
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 390
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 391
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 392
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 393
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 394
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 395
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 396
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 397
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 398
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 399
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 400
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 401
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 402
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 403
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 404
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 405
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 406
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 407
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 408
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 409
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 410
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 411
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 412
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 413
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 414
Suggested Citation:"C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)." Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: The National Academies Press. doi: 10.17226/5298.
×
Page 415
Next: D Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience (Workshop Summary) »
Improving Health in the Community: A Role for Performance Monitoring Get This Book
×
Buy Hardback | $79.95 Buy Ebook | $64.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

How do communities protect and improve the health of their populations? Health care is part of the answer but so are environmental protections, social and educational services, adequate nutrition, and a host of other activities.

With concern over funding constraints, making sure such activities are efficient and effective is becoming a high priority.

Improving Health in the Community explains how population-based performance monitoring programs can help communities point their efforts in the right direction.

Within a broad definition of community health, the committee addresses factors surrounding the implementation of performance monitoring and explores the "why" and "how to" of establishing mechanisms to monitor the performance of those who can influence community health. The book offers a policy framework, applies a multidimensional model of the determinants of health, and provides sets of prototype performance indicators for specific health issues.

Improving Health in the Community presents an attainable vision of a process that can achieve community-wide health benefits.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!