improve health that it becomes possible to hold specific entities accountable. The committee proposes that accountability for those actions be established within a collaborative process, not assigned. Performance monitoring is the tool that communities can then use to hold community entities accountable for actions for which they have accepted responsibility.

Based on its review of the determinants of health, the community-level forces that can influence them, and community experience with performance monitoring, the committee finds that a community health improvement process (CHIP) that includes performance monitoring, as outlined in this report, can be an effective tool for developing a shared vision and supporting a planned and integrated approach to improve community health. It offers a way for a community to address a collective responsibility and marshal resources of specific, accountable entities to improve the health of its members. The committee concluded, however, that individual communities will have to determine the specific allocation of responsibility and accountability. No universal approach can be prescribed. The committee's recommendations for operationalizing a CHIP are based on a variety of theoretical and practical models for community health improvement, continuous quality improvement, quality assurance, and performance monitoring in health care, public health, and other settings. However, the specifics of the committee's proposal have never been tested, in toto, in community settings. Therefore, attention is also given in this report to ways in which the proposed process can be evaluated.

The committee suggests that a CHIP should include two principal interacting cycles based on analysis, action, and measurement (see Figure 2). This process is described in more detail in Chapter 4. The problem identification and prioritization cycle focuses on identification and prioritization of health problems in the community, and the analysis and implementation cycle on a series of processes intended to devise, implement, and evaluate the impact of health improvement strategies to address the problems. The overall process differs from standard models primarily because of its emphasis on measurement to link performance and accountability on a community-wide basis.

This process can be applied to a variety of community circumstances, and communities can begin working at various points in either cycle, with varying resources in place. It is an iterative and evolving process rather than linear or short term. One-time activities or short-term coalitions will not be adequate. There must

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