D
Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience

Workshop Summary1

INTRODUCTION

In recent years, performance monitoring has gained increasing attention as a tool for evaluating the delivery of personal health care services and for examining population-based activities addressing the health of the public. This attention to performance monitoring is related to several factors, including concerns about ensuring the efficient and effective use of health care dollars in providing high-quality care and achieving the best possible health outcomes. Also contributing are a wider recognition that the health of the population depends on many factors beyond medical care and heightened concern about accountability for use of resources and whether desired results have been achieved.

An interest in understanding how monitoring the activities performed by health care and public health agencies and organizations might contribute to improving the health of entire communities is the basis of a study by the Institute of Medicine (IOM) Committee on Using Performance Monitoring to Improve Commu-

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This appendix is a workshop summary that has been published separately as Using Performance Monitoring to Improve Community Health: Conceptual Frame-work and Community Experience (Institute of Medicine [1996], E.M. Weissman, ed.: Washington, D.C.: National Academy Press).



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Improving Health in the Community: A Role for Performance Monitoring D Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience Workshop Summary1 INTRODUCTION In recent years, performance monitoring has gained increasing attention as a tool for evaluating the delivery of personal health care services and for examining population-based activities addressing the health of the public. This attention to performance monitoring is related to several factors, including concerns about ensuring the efficient and effective use of health care dollars in providing high-quality care and achieving the best possible health outcomes. Also contributing are a wider recognition that the health of the population depends on many factors beyond medical care and heightened concern about accountability for use of resources and whether desired results have been achieved. An interest in understanding how monitoring the activities performed by health care and public health agencies and organizations might contribute to improving the health of entire communities is the basis of a study by the Institute of Medicine (IOM) Committee on Using Performance Monitoring to Improve Commu- 1   This appendix is a workshop summary that has been published separately as Using Performance Monitoring to Improve Community Health: Conceptual Frame-work and Community Experience (Institute of Medicine [1996], E.M. Weissman, ed.: Washington, D.C.: National Academy Press).

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Improving Health in the Community: A Role for Performance Monitoring nity Health. The study is being funded by the U.S. Department of Health and Human Services and The Robert Wood Johnson Foundation. The Committee's Charge The committee was asked to examine how performance monitoring can be used to promote improvements in community health. In particular, the committee was asked to consider the roles that public health and personal health care systems and other stakeholders play in influencing community-wide health, how their performance in connection with health improvement goals can be monitored, and how a performance monitoring system can be used to foster collaboration among these sectors and promote improvements in community health. The committee brought together expertise in state and local health departments, epidemiology, public health indicators, health data, environmental health, adult and pediatric clinical medicine, managed care, community health and consumer interests, quality assessment, health services research, and employer concerns. The group met six times between February 1995 and April 1996. Workshops held in conjunction with two of these meetings gave the committee an opportunity to learn more about conceptual and applied work relevant to performance monitoring and to hear about a variety of community experiences. The Workshop The committee's second workshop, held on December 11, 1995, is summarized here. The purpose of this workshop was to discuss both conceptual models underlying performance monitoring and its use in specific communities. Workshop presentations on conceptual models addressed the determinants of health, social change, and accountability. Presentations and a panel discussion gave five professionals working in communities an opportunity to bring to the committee comments and observations based on practical experience in health improvement programs and performance monitoring. This summary of the workshop presentations and discussions is based on notes from the presentations, a transcript of the taped proceedings, and comments from the speakers. It does not present opinions, conclusions, or recommendations of the committee. Conclusions and recommendations, which will reflect consideration of

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Improving Health in the Community: A Role for Performance Monitoring the workshop discussions, will be presented in the committee's final report. BACKGROUND2 As used by the committee, the term performance monitoring refers to a continuing community-based process of selecting indicators that can be used to measure the process and outcomes of an intervention strategy for health improvement, collecting and analyzing data on those indicators, and making the results available, to the community as a whole and specifically to those segments of the community engaged in health improvement activities, to inform assessments of the effectiveness of an intervention and the contributions of accountable entities. Performance monitoring should promote health improvement in a context of shared responsibility and accountability for achieving desired outcomes. Many parties within a community share responsibility for health (e.g., consumers, health care providers, businesses, government agencies, public service groups); those with responsibility for accomplishing specific tasks are accountable to the community for their performance. 3 Several assumptions underlie the committee's approach to performance monitoring. First, it is increasingly necessary to use resources efficiently, that is, to accomplish tasks with a minimum of waste. Performance monitoring is expected to facilitate efficient approaches to improving the health of communities at a population level. Second, a performance monitoring system should have 2   This section is based on comments by Thomas Inui. 3   The committee's approach to performance monitoring relies on the public health ''core functions" of assessment and assurance (IOM, 1988) and the health care activities related to quality assessment, assurance, and improvement (see IOM, 1990). From a public health perspective, assessment is the regular collection, analysis, and dissemination of information on the health of the community. Assurance refers to a governmental responsibility to ensure that services necessary to achieve agreed upon goals are provided. Quality assessment refers to measurement of processes and outcomes of health care and their comparison against a standard. Quality assurance employs such measurement within the context of a broader set of activities that includes steps to identify and correct problems. Quality improvement uses continuous measurement and analysis of processes and outcomes not only to address problems but also to maintain and enhance good performance. The health improvement activities envisioned by the committee combine a responsibility to the community for achieving health goals with techniques like those used in quality improvement.

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Improving Health in the Community: A Role for Performance Monitoring a broad enough perspective to monitor diverse factors that influence a community's health, including ones that may not appear obviously health related. Third, a wide range of actors share a stake in community health; thus, social action and changes that involve many sectors of the community are necessary. Finally, special attention to vulnerable populations is important, because equity is valued in community health. The application of performance monitoring presents problems at the current level of knowledge and infrastructure. Although tools for indicator development exist, the conditions for creating operational monitoring systems at the community level may not. Furthermore, measurement strategies for an array of health issues are not universally available, and measures that are available may not always be applicable at the community level. In addition, most information systems are not yet able to support the identification and analysis of health problems and to track interventions. A central task for the committee is the development of indicators suitable for community-based performance monitoring.4 Ideally, performance indicators measure states or critical processes that are potentially alterable and thought to have a demonstrable relationship to health outcomes. Those indicators may be measures of capacity, resources, processes, or actual health outcomes. Committee discussions suggest that indicator selection should be based on a community process that includes identification of stakeholders, adoption of a shared conceptual framework to analyze the community's health, selection of indicators appropriate to fundamental concerns, operational development of indicators, and field testing of indicators. Indicators should be descriptive; reliable, valid, and sensitive to changes in the community's health; important to stakeholders; sensitive to declines in the health of vulnerable subpopulations; and useful in monitoring health initiatives. DETERMINANTS OF HEALTH5 Health encompasses physical and psychosocial well-being, not simply the absence of disease. Because many factors influence health and well-being, understanding the nature and scope of 4   The indicators proposed by the committee will appear in the final report for this study. 5   This section is based on a presentation by Jonathan Fielding.

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Improving Health in the Community: A Role for Performance Monitoring these determining factors is an essential element in developing health improvement strategies and in determining what indicators may be appropriate elements of a performance monitoring effort. The workshop's opening presentation used the framework of the Health Field Model for examining the determinants of health. Health Field Model A model of the determinants of health proposed by Evans and Stoddart—the health field model—provides a broad conceptual framework for considering the factors that influence health in a community (Evans and Stoddart, 1990). Unlike a biomedical model that views health as the absence of disease, the field model includes functional capacity and well-being as health outcomes of interest (see Figure D-1). The model also emphasizes general factors that affect many diseases or the health of large segments of the population, rather than specific factors that account for small changes in health at the individual level. It takes a multidisciplinary approach, uniting biomedical sciences, public health, psychology, statistics and epidemiology, economics, sociology, education, and other disciplines. Social, environmental, economic, and genetic factors are seen as contributing to differences in health status and, therefore, as presenting opportunities to intervene. Although this type of model is not an entirely new paradigm, its implications for designing health improvement programs deserve attention. For example, the way in which (health) behavior is understood fundamentally changes. Rather than a voluntary act amenable to direct intervention, behavior can be seen as an intermediate factor that is itself shaped by multiple forces, particularly the social and physical environments and genetic endowment. At the same time, behavior remains a relevant target for intervention. The model also differentiates among disease, health and function, and well-being. They are affected by separate but overlapping factors, and therefore, indicators selected to monitor health improvement programs may need to differ depending on which outcome is of primary interest. The model also reinforces the interrelatedness of many factors. Outcomes are the product of complex interactions of factors rather than of individual factors operating in isolation. It was suggested that the interactions among factors may prove to be more important than the actions of any single factor. Each of the factors included in the model is considered briefly in turn.

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Improving Health in the Community: A Role for Performance Monitoring FIGURE D-1 A model of the determinants of health. Source: Reprinted from R.G. Evans and G.L. Stoddart, 1990, Producing Health, Consuming Health Care, Social Science and Medicine 31:1359, with permission from Elsevier Science Ltd, Kidlington, UK. Social Environment Among the elements of the social environment that have been linked to health are family structure, the educational system, social networks, social class, work setting, and level of prosperity. Family structure, for example, is known to affect children's physical and mental health. On average, children in single-parent families do not do as well on measures of development, performance, and mental health as children in two-parent families. Children's relationships with their parents, social support, nurturance, and sense of self-efficacy have been shown to be related to their mental and physical health and even to their future economic productivity (Schor and Menaghan, 1995). Education has an effect on health status separate from its influence on income. Years of formal education are strongly related to age-adjusted mortality in countries as disparate as Hungary, Norway, and England and Wales (Valkonen, 1989). Although most research is based on years of formal schooling, evidence suggests a broader relationship that includes the preschool period. An assessment at age 19 of participants in the Perry Pre-

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Improving Health in the Community: A Role for Performance Monitoring school Study, which randomized children into a Head Start-like program, showed that participation in the preschool program was correlated with better school performance, attending college, and avoiding involvement with the criminal justice system (Weikart, 1989). Critical periods for education, particularly at young ages, may prove to be important in determining health. In addition, studies show that maternal educational attainment is a key determinant of child welfare and survival (Zill and Brim, 1983). "Social networks" is a term that refers to an individual's integration into a self-defined community and the degree of connectedness to other individuals and to institutions. There is a strong inverse correlation between the number and frequency of close contacts and mortality from all causes, with odds ratios of 2:1 or higher and a clear "dose-response" relationship (Berkman and Syme, 1979). Although it is possible to see the impact of social networks on health, the pathways responsible for those effects are not yet known. Social class is another well-described determinant of health, independent of income. Major studies have been done in Britain, where social class is defined more explicitly than in the United States. In the Whitehall study of British civil servants, Marmot et al. (1987) demonstrated a clear relationship between social class (based on job classification) and mortality. The relationship persists throughout the social hierarchy and is unchanged after adjusting for income and smoking. The effect of social class may raise uncomfortable issues in the United States but is important to consider in dealing with issues of health and equity. The health effects of work-related factors are seen in studies of job decision latitude, autonomy, and cardiovascular mortality (Karasek and Theorell, 1990). Involuntary unemployment negatively affects both mental and physical health. Economic prosperity is also correlated with better health. Throughout history, the poor have, on average, died at younger ages than the rich. The relationship between prosperity and health holds across the economic spectrum. For every decile, quintile, or quartile of income, from lowest to highest, there is a decline in overall age-adjusted mortality. In international comparisons by the Organization for Economic Cooperation and Development, the difference in income between the highest and lowest deciles of income shows a stronger relationship with overall mortality rates than does median income (Wilkinson, 1992, 1994).

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Improving Health in the Community: A Role for Performance Monitoring Genetic Endowment Genetic factors are recognized as having a significant influence on health, and it will be important to gain a better understanding of these influences. For the most part, genetic factors are currently understood as contributing to a greater or lesser risk for health outcomes, rather than determining them with certainty. Briefly highlighted in the presentation was the link seen between genetics and behavior. Studies of twins separated at birth demonstrate a high concordance rate in alcoholism, schizophrenia, and affective disorders (Baird, 1994). Even so-called voluntary behaviors such as smoking and eating habits may be subject to genetic predispositions (e.g., Carmelli et al., 1992; de Castro, 1993; Falciglia and Norton, 1994). Health behaviors are complex, and the influences that determine them are likely to be extremely complex. Genetic factors also interact with social and environmental factors to influence health and disease. It will be important to understand these interactions to learn why certain individuals with similar environmental exposures develop diseases whereas others do not (e.g., why most smokers do not develop lung cancer). Physical Environment The physical environment affects health and disease in diverse ways. Examples include exposures to toxic substances that produce lung disease or cancers; safety at home and work, which influences injury rates; poor housing conditions and overcrowding, which can increase the likelihood of violence, transmission of infectious diseases, and mental health problems; and urban-rural differences in cancer rates. Behavior In the field model framework, behavior is a response to the other determinants and can be seen as an "intermediate" determinant of health. It is shaped by many forces, particularly the social and physical environments and genetic endowment, as previously described. Behaviors related to health care, such as adherence to treatment regimens, are influenced by these forces as are behaviors that directly influence health, such as smoking.

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Improving Health in the Community: A Role for Performance Monitoring Health Care Health care has a limited but not negligible role as a determinant of health. Approximately 5 years of the 30-year increase in life expectancy achieved this century can be attributed to improved health services (Bunker et al., 1994). Of these 5 years, it has been estimated that curative services contribute about 3.5 and clinical preventive services about 1.5 years. The greatest share of this gain from health care can be attributed to diagnosis and treatment of coronary heart disease, which contributes 1 to 2 of these additional years of life. Linking the Determinants According to the presenter, the Evans and Stoddart field model helps in conceptualizing factors affecting health. Substantial evidence is available to support the relationship that many of these factors have with health. Currently incomplete, however, are descriptions of mechanisms underlying the linkages among the various determinants and full characterizations of the interactions among factors. Some evidence is available to demonstrate that these interactions exist. For example, high socioeconomic status is a buffer against the negative impact of perinatal stress on developmental outcomes in children at age 20 months (Werner, 1989). Similarly, high socioeconomic status reduces the negative impact of high umbilical lead levels on mental development (Bellinger et al., 1993). What is not yet available is an understanding of why the interactions occur. INTERVENTIONS TO IMPROVE HEALTH Many factors can influence the impact of interventions to improve health. It is possible to target various determinants of health to produce change at an individual level, a community level, or both. All aspects of each broad determinant of health are not equally amenable to intervention, however. For example, the social environment of isolated senior citizens can be improved by increasing contact with others, but their genetic endowment is not changeable. Time frames for change following interventions can vary widely, from days to decades. Some successful interventions will produce observable results within a year or two, but others may be followed by long latency periods before significant changes can be

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Improving Health in the Community: A Role for Performance Monitoring observed in health status. The impact of an intervention may also be influenced by when it reaches an individual because there appear to be "critical periods" in human development. Certain interventions in childhood, for example, may have long-delayed yet long-lasting results. In addition, the population effects of interventions are important to consider. Small changes at the individual level may have important ramifications when applied to a whole community (Rose, 1992). Community Interventions The literature on community interventions is diffuse and difficult to summarize. A few observations based on that literature were shared with the committee. For example, the Healthy Cities/Healthy Communities activities demonstrate that a high level of interest in community interventions exists, but these activities have not yet generated a body of evidence that will allow them to be replicated in other settings. Study designs rarely meet high scientific standards. Although literature on advocacy and the process of community change abounds, validation through outcomes research is often lacking. Information linking process with outcome is inadequate, as are details describing implementation of interventions. It was suggested that evidence that interventions have had a positive impact on the population is more likely to emerge in narrowly defined areas such as increasing immunization rates or decreasing workplace smoking. Similarly, one-time accomplishments are easier to document than what is needed to sustain activities. Literature examining the difference between attaining goals and maintaining them is lacking, and this issue requires more attention. Targets for Intervention The traditional targets for intervention have been specific diseases or behaviors. The field model of the determinants of health suggests consideration of a wider array of targets. For example, if adolescents' sense of well-being can be improved by reducing their feelings of alienation and hopelessness, can unintended pregnancies, alcohol and other drug use, crime, and the school dropout rate all be reduced? A multidimensional approach would be required, focusing on education, social and community involvement, family preservation, and improved social networks for teens and

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Improving Health in the Community: A Role for Performance Monitoring their parents. Community-level interventions might include after-school programs, athletics (e.g., midnight basketball), and church-based programs. The multidimensional approach may be unfamiliar to health professionals because it is new and relies on partnerships with people from fields beyond those traditionally encompassed by a medical model. It is, however, consistent with the field model and may provide expanded opportunities for performance monitoring and improving the community's health. The variety of ways in which community can be defined, such as geography, politics, or social networks, was also noted (Patrick and Wickizer, 1995). The committee was encouraged to consider all kinds of communities in seeking solutions to health needs. Implications for Performance Monitoring Performance monitoring should make use of measures of inputs, process, and outcomes so that their interrelationships can be studied.6 It was suggested that key determinants of health should be monitored, regardless of whether they are amenable to change at the local level, so that communities can understand the range of important factors. The value of both individual- and community-level data was emphasized. Subjective individual-level data may contribute important information about community needs. For example, information on social support, perceived barriers to service utilization, and attitudes toward the community and its resources is all relevant to health and to performance monitoring and can be obtained from community surveys. The quality of cooperation among organizations is an often-neglected consideration for which community-level measures might be developed. The success of multiple organizations serving 6   In the context of the committee's work, outcome measures describe a state of health or well-being (e.g., immunization rates) that is the product of factors that can be characterized on the basis of the field model. To monitor outcomes that change slowly, intermediate outcome measures may be used (e.g. monitoring changes in prevalence of smoking rather than changes in incidence of lung cancer). Process measures describe activities that are being performed in connection with efforts to achieve a desired outcome. Input measures (also referred to as measures of structure or capacity) describe the characteristics of resources (e.g., funds, personnel, equipment, time, policies) available or in use (e.g., number of doses of vaccine available).

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Improving Health in the Community: A Role for Performance Monitoring population health; treatment of illness versus health promotion; meeting health needs versus managing health care costs; traditional versus new organizational models; current social conditions versus societal goals; and maintaining the status quo versus shifting paradigms (Casebeer and Hannah, 1995). Regionalization of the health care system in the province of Alberta constitutes a significant change in the arrangements for managing and providing health services. The change is largely an attempt to control increased health care spending, which grew from 20 to 32 percent of the provincial government's budget between 1980-1981 and 1983-1994, and to alter the orientation of health care provision (managing the system regionally and shifting to a population-based, community-based, health-promoting focus for care). A study of change in health care and health policy identifies processes of change used by managers, as well as expected and actual health outcomes (Casebeer, 1996). Managers have suggested that successful change depends on the development of structures, processes, and outcomes that encourage the system to change in positive and sustainable ways. With regard to structures, these managers are attempting to work with new and broader governance roles; leaner, flatter, more horizontal management of the system; new working arrangements for health care providers and managers; and new participatory roles for communities. In relation to process issues, managers emphasized several critical aspects of change: the importance of sustaining political will; the pace of change; the capacity for shifting resources; the need for a renewed commitment to positive change; improved communication capabilities; better information; effective planning; and time for learning and adjusting. Managers articulated a range of hopes and concerns in relation to short-term and long-term outcomes. For example, they expect that new management structures and savings would be

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Improving Health in the Community: A Role for Performance Monitoring short-term outcomes, new ways of developing services for better information would be medium-term outcomes, and improved services and health status would be long-term outcomes. Gaining a better understanding of health care change such as that taking place in Alberta will require additional longitudinal and comparative experience as well as targeted research. COMMENTARY14 The workshop discussions served as the basis for a commentary on community-based performance monitoring and issues to which the committee should give further attention. It was noted that the day's discussions focused broadly on community health improvement and community activation, rather than focusing more narrowly on performance indicators. This perspective is consistent with many community-based efforts to reduce health risks and prevent disease, such as the National Heart Lung and Blood Institute's cardiovascular risk reduction programs or the Kaiser Family Foundation's community health promotion grants program. Coalition building was central to these programs. They emphasized ensuring community involvement and participation of key stakeholders; needs assessment; project implementation based on the needs assessment; and program monitoring and evaluation. It was suggested that although this approach, which is based on collaboration and community empowerment, is consistent with public health values, the evidence to date suggests that the model, as implemented in the past, may not work. Coalitions include varied interest groups and may be swayed by political concerns. The process may not select the most effective interventions at a population level. Efforts are being made, however, to bridge the gap that seems to exist between the community activation approach and the science of health improvement (Wandersman et al., 1995). In contrast, the HEDIS approach relies on central planning and oversight. Although its top-down approach may conflict with the values and instincts of public health practitioners, it appears to be effective in promoting change. Its effectiveness was attributed to its visibility, its evidence-based approach, and its use of measures that lend themselves to managerial action. The speaker proposed a new paradigm for community health 14   This section is based on comments by Edward Wagner.

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Improving Health in the Community: A Role for Performance Monitoring improvement based on a synthesis of community partnerships with an evidence-based approach. First, cooperation with the private sector, particularly medical care, would be a key element. Second, the private sector requires a business reason such as competition to participate. Third, performance indicators should be used to focus attention on those health issues and interventions supported by scientific evidence, as well as to generate and sustain accountability. Finally, the partnership should generate specific implementation strategies. In sum, performance indicators should support a community participation model by helping community partnerships set priorities and design interventions based on evidence. Also critical to consider is the issue of accountability. In the speaker's view, accountability should be clearly assigned within the community. It must also rest on all who have responsibility to act. For there to be true accountability, performance must be monitored. The workshop discussions suggested that performance indicators are used for multiple purposes: to identify problems and generate hypotheses, as political tools for mobilization in the community, to suggest ideas for improvement, and in fact, to monitor the performance of specific sectors of the community. Among the characteristics of useful performance indicators is a focus on populations and rates, rather than on absolute numbers of contacts involved in the interventions. In other words, the denominator is as important as the numerator. Indicators were described as most useful when they focus on areas where improvement is possible. Global health status indicators often have little practical use for guiding health improvement strategies. More useful are indicators that incorporate a "theory of improvement"—that is, they suggest a clear means of moving from measurement to action. Indicators that have been shown to change in intervention studies should be preferred over those that may be more conceptually elegant but may not be able to capture the impact of an intervention. "Responsive" indicators of this sort allow real change to be distinguished from random variation. The value of standard epidemiologic health needs assessments was questioned. Often, needs assessments merely document problems that are already well known. On the other hand, needs assessments focused on factors in the community that influence program implementation—politics, resources, barriers, key players—may be very useful. The speaker also emphasized that although coalitions are an essential component of community-based

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Improving Health in the Community: A Role for Performance Monitoring health improvement projects, they can consume substantial resources. Participants may, for example, spend an average of 3–4 hours a month conducting coalition-related work. It has also proved difficult to document a relationship between the characteristics of coalition operations and health outcomes achieved. The contributions that coalitions make to health improvement activities need to be better understood. The committee was urged to articulate a model (or models) of health improvement that specifies use of performance indicators and holds social and nonclinical improvement strategies to the same evidence base as clinical strategies. Such a model should help communities clarify accountability and consider ways in which to include the private and public sectors as accountable entities; identify performance indicators in the model of health improvement; indicators should not be expected to generate models of community improvement; illustrate its concepts with the selection of a limited number of "performance areas" that are characterized by (a) evidence that services affect health status, (b) a clear theory of improvement, and (c) some reasonable ideas about how to reach the entire population; and identify key input processes and intermediate outcomes within each performance area. CONCLUDING OBSERVATIONS15 The workshop concluded with a review of lessons for the committee, beginning with comments on the field model. The field model appears especially useful from a public health perspective. The model facilitates focusing on population effects, and its broad inclusion of disease, well-being, health, and function provides a basis for expanding monitoring systems to include these areas. The field model also provides a useful basis for addressing the committee's concern for equity in health and how to promote equity in health through a performance monitoring system. The model makes it possible to study equity as it relates to social class, family structure, education, and social networks. The model's treatment of genetics in interrelationship with other de 15   This section is based on comments by Bobbie Berkowitz.

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Improving Health in the Community: A Role for Performance Monitoring terminants and its view of behavior as an intermediate determinant are also helpful. Considering behavior as a product of various factors encourages users of the model to avoid blaming victims. Still needed, however, is better information regarding which determinants are actually amenable to intervention and whether community processes really lead to measurable community outcomes. Ways to measure cooperation are also lacking. The panel's presentations and discussion illustrated differences among programs in the degree to which goals, performance measurement, and stakeholder roles have been articulated. The discussion also pointed out that community process can be catalyzed by a triggering event. This might be the availability of funding or public outcry when a situation is unacceptable. Different communities will require different approaches to the selection and use of performance indicators. It will be a challenge for the committee to propose a system that satisfies both "cookbook" and "menu" approaches. Stakeholder identification appears to occur in two parallel tracks based on different responsibilities in some programs. One set of stakeholders is more involved in developing the information infrastructure, while the other set of stakeholders is involved in decision making or policy development. Potential trouble exists if the two groups do not communicate adequately. It was suggested that well-constructed coalitions of stakeholders can "keep the process honest." Ensuring meaningful consumer participation is another challenge shared by the programs, and is a topic that requires more attention. Panelists were sensitive to the need to listen both to stakeholders who are active participants and to those who are not before reaching conclusions about intervention strategies or performance indicators. Concern about the potential for harmful use of data provided by performance monitoring was raised. There is a possibility that data could be misused in resource allocation if overly simplistic formulas are applied, and the committee must remain aware of these risks. Communities with multiple needs and few resources might lose funding for doing poorly, or communities that are achieving positive results might be at risk of losing funding if needs are assumed to be met. A community that is addressing a difficult problem may be doing a good job if it can maintain a given level of performance. For some health issues, prevalence of HIV/AIDS infection, for example, finding only a small increase might represent progress over higher increases in the past. It is also

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Improving Health in the Community: A Role for Performance Monitoring important to monitor "what is going right" rather than just looking for poor outcomes. Final comments addressed social change issues. The models described to the committee contribute to the notion that the process of change is as important as the outcome. They also emphasize that the role of each stakeholder in the process is important for the committee to consider. 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. Baird, P.A. 1994. The Role of Genetics in Population Health. In Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. R.G. Evans, M.L. Barer, and T.R. Marmor, eds. New York: Aldine de Gruyter. Beckhard, R., and Harris, R.T. 1987. Organizational Transitions: Managing Complex Change. 2nd ed. Don Mills, Ontario: Addison Wesley. Bellinger, D., Leviton, A., Waternaux, C., Needleman, H., and Rabinowitz, M. 1993. Low-Level Lead Exposure, Social Class and Infant Development. Neurotoxicology and Teratology 10:497–504. Berkman, L.F., and Syme, S.L. 1979. Social Networks, Host Resistance, and Mortality: A Nine Year Follow-up Study of Alameda County Residents. American Journal of Epidemiology 109:186–204. Bridges, W. 1980. Transitions: Making Sense of Life's Changes. Reading, Mass.: Addison Wesley. Bunker, J.P., Frazier, H.S., and Mosteller, F. 1994. Improving Health: Measuring Effects of Medical Care. Milbank Quarterly 72(2):225–255. Carmelli, D., Swan, G.E., Robinette, D., and Fabsitz, R. 1992. Genetic Influence on Smoking: A Study of Male Twins. New England Journal of Medicine 327:829–833. Casebeer, A.L. 1996. The Process of Change Related to Health Policy Shift. Unpublished Ph.D. dissertation. Department of Community Health Services, University of Calgary. Casebeer, A.L., and Hannah, K.J. 1995. Evaluating the Process of Change Related to Health Policy Shift. Presented at Evaluation 1995—Evaluation for a New Century: A Global Perspective, Vancouver, British Columbia. November 1–5. CDC (Centers for Disease Control and Prevention). 1992. Guidelines for Assessing Vaccination Levels of the 2-Year-Old Population in a Clinic Setting. Atlanta: U.S. Department of Health and Human Services, Public Health Service . de Castro, J.M. 1993. Genetic Influences on Daily Intake and Meal Patterns of Humans. Physiology and Behavior 53:777–782. Evans, R.G., and Stoddart, G.L. 1990. Producing Health. Consuming Health Care. Social Science and Medicine 31:1347–1363.

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Improving Health in the Community: A Role for Performance Monitoring WORKSHOP AGENDA December 11, 1995 Foundry Building—Room 2004 1055 Thomas Jefferson Street, N.W., Washington, D.C. 8:30 a.m. Welcome and Overview of the Committee's Approach to Performance Monitoring   Thomas Inui, Harvard Medical School 9:00 a.m. Presentation and Discussion on Determinants of Health   Jonathan Fielding, University of California at Los Angeles 10:00 a.m. Community Experience with Performance Monitoring   Moderator: Alan Cross, University of North Carolina   Brief Program Descriptions     J. Maichle Bacon, McPlan, the McHenry County (Illinois) Project for Local Assessment of Need     Dennis Kelso, Health Care and Community Services Project (Escondido, California)     Tony Traino, North Shore Community Health Network (Massachusetts)     Laurie Carmody, Arizona Partnership for Infant Immunization     Bonnie Rencher, Calhoun County (Michigan) Health Improvement Program 11:00 a.m. Panel Discussion:   Committee Questions on Performance Monitoring Experience and Perspectives 12:30 p.m. Lunch 1:30 p.m. Continue Panel Discussion 3:15 p.m. Break 3:30 p.m. Presentation and Discussion on Issues of Social Change and Accountability   Ann Casebeer, University of Calgary 4:15 p.m. Commentary and Response   Edward Wagner, Group Health Cooperative of Puget Sound and University of Washington 4:45 p.m. Concluding Discussion and Comments   Bobbie Berkowitz, Washington State Department of Health 5:15 p.m. Adjourn

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Improving Health in the Community: A Role for Performance Monitoring WORKSHOP SPEAKERS AND GUESTS Speakers J. MAICHLE BACON, Public Health Administrator, McHenry County Department of Health, Woodstock, Illinois LAURIE L. CARMODY, Public Health Consultant, Group Health Association of America, Washington, D.C. ANN CASEBEER, Doctoral Candidate, University of Calgary, Department of Community Health Sciences, Calgary, Alberta JONATHAN E. FIELDING, Professor of Health Services and Pediatrics, University of California at Los Angeles, Los Angeles, California DENNIS J. KELSO, Director, Health Care and Community Services Project, Escondido, California BONNIE RENCHER, Community Outreach Coordinator, Calhoun County Health Improvement Program, Battle Creek, Michigan TONY TRAINO, Associate Director, Home Care Operations, Visiting Nurse Association of Greater Salem, Salem, Massachusetts EDWARD H. WAGNER, Director, Center for Health Studies and W.A. (Sandy) MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, Seattle, Washington Invited Guests DENNIS P. ANDRULIS, National Public Health and Hospital Institute, Washington, D.C. MICHAEL BARRY, Public Health Foundation, Washington, D.C. GEORGES C. BENJAMIN, Public Health Services, Department of Health and Mental Hygiene, Baltimore, Maryland CHERYL BEVERSDORF, Association of State and Territorial Health Officials, Washington, D.C. JACKIE BRYAN, Association of State and Territorial Health Officials, Washington, D.C. LINDA K. DEMLO, Agency for Health Care Policy and Research, Rockville, Maryland PATRICIA A. EBENER, Behavioral Scientist, RAND, Santa Monica, California MARGO EDMUNDS, Institute of Medicine, Washington, D.C. SARA GARSON, Center for the Advancement of Health, Washington, D.C. CAREN GINSBERG, National Public Health and Hospital Institute, Washington, D.C. SUSANNA GINSBURG, Lewin-VHI, Inc., Fairfax, Virginia HOLLY GRASON, Child and Adolescent Health Policy Center, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland

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Improving Health in the Community: A Role for Performance Monitoring CLAUDE H. HALL, JR., Public Health Innovations Project, American Public Health Association, Washington, D.C. RICHARD HEGNER, National Health Policy Forum, Washington, D.C. PHYLLIS E. KAYE, American Health Planning Association, Washington, D.C. ROZ LASKER, The New York Academy of Medicine, New York, New York J. MICHAEL MCGINNIS, National Research Council, Washington, D.C. CATHY MERCIL, National Committee for Quality Assurance, Washington, D.C. MICHAEL MILLMAN, Health Resources and Services Administration, Rockville, Maryland NANCY RAWDING, National Association of County and City Health Officials, Washington, D.C. JORDAN RICHLAND, Partnership for Prevention, Washington, D.C. JAMES SCANLON, U.S. Department of Health and Human Services, Washington, D.C. JOSEPH THOMPSON, U.S. Department of Health and Human Services, Washington, D.C. KAREN TROCCOLI, National Association of County and City Health Officials, Washington, D.C. JAMES WEED, National Center for Health Statistics, Hyattsville, Maryland RONALD WILSON, National Center for Health Statistics, Hyattsville, Maryland