tors are advantageous for making comparisons within and between communities, for simplifying the synthesis of data from different sources, and for developing data systems. However, in designing and monitoring interventions in individual communities, the development of more specific indices may be helpful and standardization may be less important.

It was also suggested that the dichotomy between standardization and individualization is artificial. Most programs would benefit from a combination of the two. A basic set of indicators could be developed, with modifications based on specific community needs. Alternatively, a broad spectrum of questions could be developed from which communities could choose appropriate subsets. The selection of indicators may be especially difficult in a diverse community. Participants pointed out that performance indicators could be coordinated with currently existing health indicators in the private and public sectors such as HEDIS 2.0 (NCQA, 1993), APEXPH (NACHO, 1991), Model Standards (APHA et al., 1991), and Healthy People 2000 (USDHHS, 1991).

Development of performance indicators requires stakeholder involvement. Some participants emphasized the importance of including private-sector stakeholders early in the planning stages in order to frame questions in a manner compatible with existing data bases. Distinguishing performance indicators from overall program evaluation was raised as an important distinction. The speaker suggested that performance monitoring should focus on the component parts of an intervention whereas program evaluation should examine the overall outcome.

Role of Performance Indicators in Stakeholder Accountability

Workshop participants agreed that defining accountability—which "actors" are responsible for what functions—is extremely important. Accountability for both process and outcome goals needs to be determined. The programs described at the workshop vary in how they hold groups accountable. For example, TAPII has led to ties between capitation and immunization rates, which fosters competition among health plans. Competition as a mechanism to gain accountability may be especially useful in the private sector. The Escondido program addresses accountability through formal written agreements detailing participation in the project, contract arrangements with providers, target rates for screening and performance, and management information systems for the integrated services. In other programs represented at the work-



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