3
Managing a Shared Responsibility for the Health of a Community

The health of a community is a shared responsibility of all its members. Although the roles of many community members are not within the traditional domain of ''health activities," each has an effect on and a stake in community's health (Patrick and Wickizer, 1995). As communities try to address their health issues in a comprehensive manner, all parties—including individual health care providers, public health agencies, health care organizations, purchasers of health services, local governments, employers, schools, faith communities, community-based organizations, the media, policymakers, and the public—will need to sort out their roles and responsibilities, individually and collectively. These interdependent sectors must address issues of accountability and shared responsibility for various aspects of community health. They also must participate in the process of "community-wide social change" that is needed for performance monitoring to succeed in improving health. In most communities, there will be only limited experience with collaborative or coordinated efforts among these diverse groups. To work together effectively, they will need a common language and an understanding of the multidimensional nature of the determinants of health. They must also find a way to accommodate diversity in values and goals.

As noted in Chapter 1, the committee has adopted as a basis for its discussions of community a description offered by Labonte (1988): individuals with shared affinity, and perhaps a shared



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Improving Health in the Community: A Role for Performance Monitoring 3 Managing a Shared Responsibility for the Health of a Community The health of a community is a shared responsibility of all its members. Although the roles of many community members are not within the traditional domain of ''health activities," each has an effect on and a stake in community's health (Patrick and Wickizer, 1995). As communities try to address their health issues in a comprehensive manner, all parties—including individual health care providers, public health agencies, health care organizations, purchasers of health services, local governments, employers, schools, faith communities, community-based organizations, the media, policymakers, and the public—will need to sort out their roles and responsibilities, individually and collectively. These interdependent sectors must address issues of accountability and shared responsibility for various aspects of community health. They also must participate in the process of "community-wide social change" that is needed for performance monitoring to succeed in improving health. In most communities, there will be only limited experience with collaborative or coordinated efforts among these diverse groups. To work together effectively, they will need a common language and an understanding of the multidimensional nature of the determinants of health. They must also find a way to accommodate diversity in values and goals. As noted in Chapter 1, the committee has adopted as a basis for its discussions of community a description offered by Labonte (1988): individuals with shared affinity, and perhaps a shared

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Improving Health in the Community: A Role for Performance Monitoring geography, who organize around an issue, with collective discussion, decision making, and action. Geography, however, emerged as a critical point of reference in the committee's discussions. Although geographic (or civic) boundaries cannot adequately capture all of the potentially meaningful community configurations, they are a practical starting point. This chapter begins with a discussion of the social and political realities of engaging communities in performance monitoring activities to improve community health. It proposes an approach in which responsibility for health goals is shared among community stakeholders and accountability for specific accomplishments is ascribed to individual entities. Strategies for managing the process of community-wide change are presented in the final section. SOCIAL AND POLITICAL CONTEXT FOR IMPROVING COMMUNITY HEALTH As communities undertake health improvement efforts, they need to be informed about the social and political environments in which a health system operates at the local, state, and national levels; ways in which those environments influence the health system; and ways in which the health system influences those environments. At the national level, health care emerged as a high-priority issue in 1992. This reflected several factors related to underlying conflicts in the needs, resources, and values of various sectors of American society. First, questions have been raised about the limit to which the country can invest in health care. No nation spends a greater share of its national income on health care than the United States (Levit et al., 1994), and concerns about the unbridled growth of health care spending are so widespread that they have become the subject of presidential political debates. Proposals to constrain spending in the public sector for services to vulnerable populations (e.g., Medicaid and Medicare) raise questions about economic disparity in the nation. In the private sector, employers are concerned about their ability to meet current and future financial obligations to provide health benefits for employees. Similar concerns extend to health care institutions, which continue to absorb losses for charity care. A second factor in the emergence of health as a high priority national issue has been politics. Health care was viewed as an important issue in the senatorial and presidential elections of

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Improving Health in the Community: A Role for Performance Monitoring 1992. As the new administration took office, health care reform was a prominent initiative. Failure to reach consensus on national health care legislation in 1993–1994 indicates the level of conflict between stakeholders over needs, resources, and values. Conflicts were most striking with regard to balancing responsibility between federal and state levels of government. Federal legislators placed a higher value on the states' rights to determine health care policy for their populations than on having a uniform national health care policy. Conflicts also arose in balancing the needs of the uninsured and other vulnerable populations (served by programs such as Medicaid and Medicare) and the political goal of a balanced budget. A third factor has been the pervasive and growing anxiety of individuals and families about health care coverage. Because health insurance in the United States is most often provided through employer-based programs, this concern reflects, in part, a growing sense of insecurity about employment. It also reflects an ambiguity about where the responsibility for health care insurance lies. Although considered an entitlement by some, there is a growing sense that responsibility for health care is being placed on the individual. After much negotiation and compromise, federal legislators have found common ground on certain aspects of this issue. Two years after the demise of comprehensive health care reform legislation, a bipartisan bill—the Health Insurance Portability and Accountability Act of 1996—addressing the portability of employment-based health insurance and prohibiting the denial of coverage for preexisting conditions was signed into law. Conflicts at the national level over issues of accessibility, quality, and affordability of health care reflect the vastly different needs, resources, and values of stakeholders in the health system. Within communities, especially in a pluralistic society such as the United States, there also is considerable diversity among stakeholders in their perspectives, interests, needs, resources, values, influence, and access to power. For example, the public values health care that is affordable, places no limits on choice, provides comprehensive benefits, limits the financial risk to consumers, and offers open access. Group purchasers and payers attempt to balance the needs of their covered populations against the need for predictable and minimal financial liability, protection against legal and ethical dilemmas, and administrative simplicity. Health care providers want to optimize patient interests while maximizing revenues and minimizing intrusion from third parties. Policymakers serve to protect the perceived interests of the com-

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Improving Health in the Community: A Role for Performance Monitoring munity regarding public health and personal health care services, thereby promoting the well-being of the population while also providing fiscal and legal oversight of public expenditures for health care. As communities try to address their health issues in a comprehensive manner, all relevant parties will have to be engaged so that their roles and responsibilities can be examined. The field model (presented in Chapter 2) identifies the broad range of factors that influence a community's health, and these suggest a variety of public and private entities that, through their actions, can influence the health of the community. Such entities can include health care providers, public health agencies, and community-based organizations explicitly concerned with health. They can also include other government agencies, community organizations, private industry, and other entities that do not explicitly, or sometimes even consciously, see themselves as having a health-related role—for example, schools, employers, social service and housing agencies, transportation and justice departments, faith communities, and the media. Although many of the entities that play an essential role in determining local health status are based in and focus their attention on the community in question, others, such as state health departments, federal agencies, managed care organizations, foundations, and national corporations, have a broader scope than a single community. For a performance monitoring effort to succeed, communities will have to do more than identify relevant parties; they will have to find effective ways to engage parties with varying needs, resources, and values; to set goals for the performance monitoring effort; to ascribe responsibility for meeting these goals; and to manage the complex process of community-wide change. Assessments of other initiatives (e.g., Newacheck et al., 1995) suggest that communities will have to overcome barriers such as the absence of performance monitoring models with demonstrated effectiveness, political difficulties in gaining cooperation and commitment from multiple parties, challenges in implementing a new program when the health care system itself is undergoing changes, and the complications of maneuvering through legislative and regulatory restrictions. Growing Concerns About Accountability and Shared Responsibility Currently, the health care system is accountable to numerous parties for a variety of activities. Accountability is promoted by

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Improving Health in the Community: A Role for Performance Monitoring ethics and professional norms, politics, and law. Regulatory agencies have a long history of holding the health care system accountable for meeting standards for the quality of care, access to care, and provision of certain data. Competition and enlightened self-interest also influence the health system to maintain high standards and to continually improve its standards. Yet, there is a growing public concern about accountability (Rodwin, 1996). Questions exist about the value the population receives for the money the nation spends on health and health care. Moreover, with the increasing complexity and changing nature of the health care system, the public wants to know which entities are responsible for specific tasks. In addition, the market forces that are restructuring the health care system demand accountability. Given the pressure for accountability, there is surprisingly little evidence in the nation of coordinated efforts to examine the performance of the health care system as it relates to the overall health of a community's population, and there is little evidence of coordinated efforts to examine the performance of entities other than health care providers that influence health. During a workshop held in December 1995, the committee heard from representatives of community-based health improvement activities (see Appendix D). None of the programs assigned accountability for tasks and use of performance-related measurement was limited. Communities need to meet this challenge. The committee has concluded that a coordinated effort to monitor the performance of the health system in communities, which involves a broad range of stakeholders, would yield tremendous benefits. Such efforts may improve the health of a community's population by providing a process for working toward health goals and a toolbox for measuring progress (see Chapter 4). It is likely that one of the most difficult tasks in implementing a community-wide and cooperative performance monitoring system will be developing an approach for ascribing accountability to stakeholders. For the purposes of this report, the committee has distinguished stakeholders and "accountable entities" in relation to the roles they play in the process of improving community health. Stakeholders are organizations and individuals who have an interest in the health of a community's population. As a group, stakeholders should include consumers, providers, businesses, government, and other relevant sectors of the community. In a performance monitoring effort, stakeholders share responsibility for the community's health. The group of stakeholders may ex-

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Improving Health in the Community: A Role for Performance Monitoring pand or contract in number, and membership may change during the performance monitoring activity. The changes in stakeholders may reflect changes in the health issues and strategies that are being considered. Accountable entities are stakeholders that are expected to achieve specific results as part of the community's strategy for addressing a health issue. The process of ascribing accountability for particular actions to specific accountable entities will differ from problem to problem, from strategy to strategy, from time to time, and from place to place. The basis for designating a stakeholder as an accountable entity may be voluntary assumption, enlightened self-interest, regulatory requirements, legislative mandate, court order, social pressure, market forces, lobbying, or other reasons. As with stakeholders, the entities that are to be accountable for specific tasks may change during the performance monitoring activity in response to progress or to changes in the issues being addressed and strategies being followed. Changing Our Approach to Accountability Traditionally, accountability in public health and medicine has been viewed from a managerial perspective as a vertical, or top-down, process. Federal funding agencies often place reporting demands on those receiving funds at state and local levels. States are required to submit reports indicating the number and types of services provided. At the community level, local health agencies and community-based organizations are required to report to a myriad of federal, state, and local government funding agencies. Reporting requirements often are not coordinated and the reports often are not shared with communities unless interested parties request them. More recently, local organizations have become advocates of a different approach to accountability. For example, as part of a public health reengineering initiative in Illinois called Project Health, local health agencies suggested that they should be accountable to the communities that they serve (Illinois Local Health Liaison Committee, 1994). Although the committee acknowledges that some activities necessitate accountability to state and federal agencies, it applauds efforts to involve communities in the accountability process and to make accountability meaningful at the local level. Similar changes are occurring in the private sector, especially among health care plans. The National Committee for Quality

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Improving Health in the Community: A Role for Performance Monitoring 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 (NCQA, 1993). It uses performance measurement to provide information that can be used to assess health plans' effectiveness in providing services and to identify areas for improvement. NCQA has begun to solicit consumer input, but the impact of this input has not yet been evaluated. More recently, a coalition of health care purchasers and consumer organizations established the Foundation for Accountability (FAcct, 1995), which is developing sets of measures that can be applied to care for specific health conditions. The Promise of Accountability at the Community Level As the committee considered ways in which to encourage, implement, and enforce accountability in the health system, it has embraced procedures that foster the promises of performance monitoring. It views these promises as (1) creating a process that encourages stakeholders to come to the table in a productive way; (2) influencing stakeholders and communities to adopt a broader model of health and to structure their health systems to reflect the model; (3) providing meaningful incentives for performing well; and (4) furnishing a set of measurement tools that will help communities examine changes in the health and well-being of their populations. In order to fulfill its promise, accountability needs to be conceptualized as a collaborative and cooperative process as opposed to a punitive process imposed by outside forces. This approach can be viewed as moving from a vertical to a horizontal structure or from a "top-down" to a "roundtable" approach. Accountability for improving health should be an open process that involves stakeholder participation and negotiation. The committee proposes a two-step approach to accountability. The first step involves the issue of shared responsibility. Communities should acknowledge that all stakeholders share responsibility for improving the health of a community's population. Stakeholders include a wide range of organizations and individuals who have an interest in the health of a community. As stated earlier, the group of stakeholders may expand or contract in number or change in membership in response to changes in the health issues and strategies being considered. Sharing responsibility should not be viewed as an insurmount-

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Improving Health in the Community: A Role for Performance Monitoring able barrier to establishing practical procedures for measuring accountability. Holding a dialogue about the shared responsibility of stakeholders for overall performance of the health system (e.g., meeting a specific health goal such as full immunization of all children by age 2) prompts stakeholders to recognize that they function as part of a larger system (Jencks, 1994). The second step in accountability involves designating accountable entities. As mentioned above, accountable entities are the stakeholders who are responsible for accomplishing specific results as part of a community's strategy for addressing a health issue. The committee suggests that the process of ascribing accountability for particular actions to specific accountable entities will differ depending on the problem and the strategies being considered, and other circumstances specific to each community. The basis for designating a stakeholder as an accountable entity may vary, depending on the ways in which communities are organized and on the interests, values, and resources of their stakeholders, However, accountability may be ascribed for various reasons (voluntary assumption, enlightened self-interest, regulatory requirements, legislative mandate, court order, social pressures, market forces, lobbying, and so on). The process of ascribing accountability should be open and should involve all relevant stakeholders. At its conclusion, the stakeholders will have established a social contract that identifies goals, areas of responsibility, and accountable entities. The committee suggests that successful performance should be rewarded. Failures to perform should trigger problem analysis and a reformulation of the stakeholder's approach to the health issue. However, penalties might also be considered, depending on the circumstances. Such decisions should be made by the stakeholders. KEY CONCEPTS FOR MANAGING CHANGE The development of performance monitoring systems will typically require change—changes in the roles played by different stakeholders, in the relationships among stakeholders, and often in the behaviors required or expected of certain participants. For example, health care providers and health plans may have to collect and make available new or different data. In most communities, there will be only limited experience with managing such change and with accommodating diversity in values and goals. This section provides key concepts for such activities.

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Improving Health in the Community: A Role for Performance Monitoring Resistance to Change Change is frequently resisted by those who are expected to do the changing. Similarly, those who perceive that others want to judge or monitor their performance, or hold them accountable for their performance, frequently resist. It is critical that change agents (i.e., those individuals who are leading the effort for change) recognize that such resistance is fairly normal; most individuals prefer to have greater control over their circumstances, value at least some elements of the status quo, and are anxious about the unknown. Although Western cultures tend to place a positive value on change and progress, communities, organizations, groups, and individuals vary in their responses to change. The response to proposed changes will depend on the content and process of change. Even when the content of change is acceptable, change is likely to be resisted if the process and pace are not acceptable. Change agents can increase the likelihood that communities will be receptive if they consider the following principles from the literature: Involve all relevant stakeholders in the change process as early as possible. Responses to proposed changes are significantly mediated by the extent of involvement of a particular group in the process of deciding that change is needed, in designing the change to be implemented, and in determining the pace of change. Groups that are not involved frequently become barriers to change, even if the proposed change is arguably in their best interest. In the performance monitoring system that the committee envisions, multiple stakeholders should be involved in the change processes so that the process becomes jointly owned rather than controlled by a single or small set of stakeholders. The process should be inclusive and open to newcomers. Understand what stakeholders value about the current system. All change, even change for the better, involves some loss for someone. In the course of change, there is an inescapable but valuable tension between the desire to remain attached, committed, and loyal to circumstances and experiences that were important in the past and the desire to embrace and move into the future. Acceptance of change depends on the ability to identify what is most valuable from the past and find a way to bring it, albeit in a transformed manner, into the future. Often, stakeholders are stigmatized as "resistant to change" when the change agent

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Improving Health in the Community: A Role for Performance Monitoring has failed to understand what those stakeholders value, and fear losing, in the current system (Marris, 1986). The incentives and motivations of stakeholders will vary. Change agents should model in their own behavior the ability and willingness to change. Thus, those who take the lead in performance monitoring efforts need to demonstrate that they can and will make difficult changes and adaptations themselves, even as they ask others to do the same. Whenever possible, introduce new resources to ease the process of change. Change typically involves making decisions that are difficult, especially when institutions and communities are operating in a context of limited resources. Change may be facilitated by the introduction of new resources; it is always made more difficult, and generates greater conflict, if it is accompanied by reductions in resources. It may well be that change will require a redistribution of resources. This is among the most difficult kinds of change to achieve because there are always perceptions of "winners" and "losers." Performance monitoring systems may be designed explicitly to support the reallocation of resources to high performers and away from low performers (e.g., by providing report cards to consumers that encourage them to select health plans or obtain services from providers who give "value" for money). Even if performance monitoring systems are not explicitly designed in this way, experience indicates that those being monitored will presume that resources are at stake and that they may lose as well as win. Frequently, those who are most supportive of change, or least resistant to it, are those who have confidence in their ability to ''win" (Marris, 1986). Alternate Approaches to the Change Process The process of change can be approached through two basic models, an authoritarian model and a willing compliance model. Although the authoritarian model has, in fact, been used to implement many changes, the committee suggests that it is an inappropriate approach to performance monitoring in communities. The authoritarian model creates circumstances in which important stakeholders must change to survive. This model presumes that one or more parties have sufficient power over the circumstances of those who are expected to change and that they also have the desire and the will to "drive change." Although there is consider-

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Improving Health in the Community: A Role for Performance Monitoring able concentration of power in American society, there is no one single center of power. Therefore, those trying to drive change are facing others who may have less power than they do, but who do have some power. The use of power often results in the development and exercise of countervailing power. When resistance rises, it is possible for the balance of power to shift unexpectedly and dramatically, thereby overturning the change. Change may be difficult to sustain when it is approached through the authoritarian model. When people comply unwillingly, they typically live up only to the letter, rarely to the spirit, of what they perceive is required. Given the complexity and subtlety of the behaviors that will be required to improve community health, it is unlikely that they will be elicited in a sustained manner from unwilling compliers. Even when only simple and easily observable behaviors are being pursued, forcing such behaviors from unwilling compliers is an expensive and probably never-ending proposition. In today's health care delivery system, much costly "micromanagement" is a consequence of presumptions that cooperation will not be forthcoming from those whose performance is being monitored. Instead, the committee suggests that communities adopt the second model for approaching the change process, that of willing compliance with mutually established strategies. Founded on co-operation, collaboration, and negotiation, the willing compliance model is appropriate for community-based work and is more likely to result in sustainable changes. A good deal of the literature in organizational change emphasizes strategies that reduce (if not eliminate) resistance to the content, direction, process, and pace of change. The committee suggests that communities use the successful strategies and tactics for achieving change shown in Box 3-1. Many of these "noncoercive" strategies can be used not only directly (i.e., with those who are being asked to change) but also indirectly, to convince additional parties to support the direction of change. However, it is unlikely that significant change will occur without some degree of conflict. Some who resist change may do so because they are uncomfortable with conflict. Among the common responses to conflict are avoidance, denial, acknowledgment, escalation, management, and resolution. It is possible that within an overall strategy of willing compliance, some parties will use authoritarian relationships to gain participation or change from others. This adds to the conflict that must be resolved. Those who pursue change must be prepared to encounter and

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Improving Health in the Community: A Role for Performance Monitoring BOX 3-1 SUCCESSFUL STRATEGIES AND TACTICS FOR ACHIEVING CHANGE Using information and logic to make a convincing cognitive case for change Using persuasion to make a convincing case for change that typically has both a cognitive and a normative or affective component Using positive incentives to encourage parties to at least consider changes or try them out; similarly, using rewards for those who change in desired directions Involving all stakeholders who are likely to be asked to change in some or all aspects of the change process Encouraging a sense that all stakeholders, including the change agents, will have to change, not just a subset Supporting the development of consensus Identifying areas of differing opinion ("dissensus") and developing strategies for proceeding in the face of such differences Creating controlled experiments or health improvement projects to try out changes on a small scale before moving to their full-scale adoption Disaggregating changes so they can be pursued incrementally and in stages Creating fallback positions or protections if the consequences of change are especially burdensome for one or another party Focusing on the common mission and vision—to improve the health of the community acknowledge conflicts and must have the resources necessary to support conflict management and resolution. Lessons from Community Coalition Building The committee's approach to using performance monitoring to improve community health assumes that a vehicle exists or will be created to bring together important stakeholders from multiple sectors, both to guide and to legitimate the process. Community coalitions, in their many forms, are one such vehicle. The capacity to mobilize multiparty groups such as community coalitions, and to support their ability to make decisions and take actions, is important to an effective performance monitoring system. Community coalitions—defined as organizations of individuals representing diverse organizations, factions, or constituencies who

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Improving Health in the Community: A Role for Performance Monitoring agree to work together in order to achieve common goals (Feighery and Rogers, 1990)—have become a popular vehicle for addressing complex social issues. Coalitions in the area of health tend to have a long-term and multifaceted focus and to be directed toward substantive and seemingly intractable problems such as violence and drug abuse. These coalitions are often action oriented. They serve as vehicles for bringing together public agencies, interest groups, and community members for planning, coordinating, and advocating in areas of mutual interest on behalf of the community. Coalitions can be based in a public agency or a community setting (Butterfoss et al., 1993). Research on coalition building is under way, and factors that influence the success of these entities are being investigated. Early findings indicate that the maturation of coalitions into entities that can successfully carry out activities requires time, effort, and resources. Coalitions progress through a series of developmental stages that include an early stage in which members form relationships; a middle stage in which members prepare to take action; a mature stage in which members take action; and a final stage in which members disband or restructure. Development through the stages is not always linear, and some coalitions never reach the mature stage (Sofaer, 1992). Preliminary findings from the Massachusetts Community Health Network Areas affirms these conclusions (D.K. Walker, personal communication, 1996). The ability of a coalition to undertake activities will be determined by its key dimensions such as its stated purpose; whether it is mandated by law or a voluntary entity; and its jurisdictional scope, membership, representation, available resources, structure, leadership, and decision-making ability (Sofaer, 1992). Foundation-supported research and demonstration efforts will provide new information about coalition building and maintenance. For example, support from The Robert Wood Johnson Foundation and the federal Center for Substance Abuse Prevention has helped in the formation of local community partnerships and coalitions that focus on the problems of alcohol, tobacco, and other drug abuse. The development of practical tools for program evaluation and other essential activities has also been supported by foundations and federal agencies (Linney and Wandersman, 1996). More recently, a large research and demonstration effort called the Community Care Network (CCN) has begun with funding from the W.K. Kellogg Foundation and The Duke Endowment. The program is being led by the American Hospital Association Hospi-

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Improving Health in the Community: A Role for Performance Monitoring tal Research and Educational Trust in collaboration with the Catholic Health Association and VHA Inc. Through the CCN program, 25 coalitions of local organizations received funding in 1995 to create healthier communities (AHA, 1995). Researchers will monitor and analyze the coalitions, with the goal of developing tools to aid other interested health organizations. Public health agencies are also promoting coalition building. The examples in Boxes 3-2 and 3-3 illustrate different approaches. IMPLICATIONS FOR PERFORMANCE MONITORING TO IMPROVE COMMUNITY HEALTH Some of the attributes that are either desirable or essential for managing change as a performance monitoring system is implemented at the community level include: will, commitment, patience, persistence, and pacing; leadership, including the capacity to develop and include new leaders; skills in communicating (advocating) effectively to policy-makers in all sectors; the ability to generate and mobilize existing resources; the ability not only to access, integrate, and interpret data on system performance and on community needs, values, and preferences, but to transform data into information; the ability to assess the value added by current resource allocations and to project future resource needs and levels; the ability to set priorities across competing interests, concerns, and structures that link priority setting to the allocation and reallocation of resources; cultural competence—the ability to recognize and work with organizations, groups, and individuals from multiple cultures (including not only "ethnic" cultures but "professional" or "organizational'' cultures); a parallel competence—the ability to integrate and utilize analytic methods and solutions from multiple academic and professional disciplines (health is inherently multidimensional); the ability to involve consumers and lay persons and to build their capacity for intelligent and equal involvement with professionals, and to recognize that they have their own unique expertise; and formal and informal organizational structures to facilitate collaboration and interchange; there is a growing literature ad-

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Improving Health in the Community: A Role for Performance Monitoring BOX 3-2 KING COUNTY, WASHINGTON King County, Washington, has found that coalitions of community stakeholders (e.g., public health agencies, health plans, hospitals, providers, employers, and others) should be developed early in the health assessment process. Such groups can provide valuable guidance on selecting indicators, interpreting assessment results, and understanding their policy implications. Public meetings and advisory groups that include community leaders can involve an even broader segment of the community in health assessment and planning. This kind of participation promotes greater "ownership" of the process and the results. Facilitating access to assessment data has also increased support for these activities. Currently in Seattle-King County, data are available to a relatively limited technical audience, but there are hopes of providing broad community access. In King County, the local health department is a resource for essential technical and organizational services for community health assessment. It provides the expertise and computing facilities needed to frame some indicator and to perform data management and analysis tasks. The health department also helps bring together the community stakeholders and helps build coalitions. SOURCE: J. Krieger, workshop presentation (1995); see Appendix C. dressed to the development of partnerships, coalitions, consortia, federations and other entities, and to their role in promoting change in general and improvements in health in particular. CONCLUSIONS Improving the health of a community will typically require change—changes in the roles played by different stakeholders, in the relationships among stakeholders, and often in the behaviors required or expected by certain participants. Performance monitoring is a tool for promoting such change. The committee suggests that communities adopt an approach to performance monitoring that is cooperative and collaborative. In addition, the committee suggests that communities use the successful change strategies and tactics described in this chapter. The committee's approach to using performance monitoring to improve community health assumes that a vehicle exists or will

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Improving Health in the Community: A Role for Performance Monitoring BOX 3-3 MASSACHUSETTS COMMUNITY HEALTH NETWORK AREAS In Massachusetts, the Department of Public Health has divided the state into 27 Community Health Network Areas (CHNAs). In each area, those interested in the improvement of health for their community are invited to work together to design a health improvement project that responds to health needs and health disparities. Each agency that receives funds from the Department of Public Health is required to participate in the CHNA. In all CHNAs, consumers are encouraged to participate in the development of health improvement strategies. Central to this effort is the systematic use of health status data to inform the development of improvement strategies. The Department of Public Health has developed a set of health status indicators for each of the 27 CHNAs that provide demographic information, birth and death statistics, incidence of infectious disease, perinatal and child health indicators, hospital discharge data, and substance abuse data in comparison with the state, the nation, and Healthy People 2000 (USDHHS, 1991) objectives. The data are available in written profiles, and the Department of Public Health anticipates making data available electronically. In each CHNA, the profile data provide a picture of health status but are only a starting point. Other data sets and qualitative analysis have been added to develop an even more comprehensive basis for identifying health issues in some CHNAs. Based on the initial data, each CHNA has selected at least one health indicator to focus on for its initial work; several CHNAs have more than one health improvement activity. Although the structure and organization of each CHNA differ, each has been established based on a common set of guiding principles. CHNAs are committed to continuous improvement of health status; focused on tracking area health status indicators and eliminating identified disparities; consumer oriented; inclusive of key stakeholders in health improvement—consumers, local government and business, and providers of community-based health, education, and human services; reflective of the diversity of the area, including racial, ethnic, gender, age, sexual orientation, and linguistic diversity; and a working partnership among the Department of Public Health, consumers, and local service providers. SOURCE: Massachusetts Department of Public Health (1995); D.K. Walker, personal communication (1996).

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Improving Health in the Community: A Role for Performance Monitoring be created to bring together important stakeholders from multiple sectors both to guide and to legitimate the process. Community coalitions, in their many forms, are one such vehicle. Through these vehicles, communities can identify relevant parties; find effective ways to engage parties with varying needs, resources, and values; set goals for the performance monitoring effort; ascribe responsibility for meeting goals; and manage the complex process of community-wide change. Communities need to identify a variety of public and private stakeholders that can influence the health of their populations. These stakeholders can include health care providers, public health agencies, and community-based organizations explicitly concerned with health. They can also include other government agencies, community organizations, private industry, and other entities that do not explicitly, or sometimes even consciously, see themselves as having a health-related role—for example, schools, employers, social service and housing agencies, transportation and justice departments, faith communities, and the media. The committee proposes a two-step approach to accountability. The first step involves the issue of shared responsibility. Communities should acknowledge that all stakeholders share responsibility for improving the health of a community's population. The second step involves ascribing to specific stakeholders accountability for accomplishing specific results as part of the community's strategy for addressing a health issue. Accountability should be conceptualized as a collaborative and cooperative process rather than a punitive process imposed by outside forces. This approach can be viewed as moving from a vertical to a horizontal structure, or from a top-down approach to a roundtable approach. A process for putting these concepts into action is described in Chapter 4. REFERENCES AHA (American Hospital Association). 1995. News Release. 25 Partnerships Named to Receive Grants in Community Network Competition. Washington, D.C. August 22. Butterfoss, F.D., Goodman, R.M., and Wandersman, A. 1993. Community Coalitions for Prevention and Health Promotion. Health Education Research 8(3):315–330. Feighery, E., and Rogers, T. 1990. Building and Maintaining Effective Coalitions. How-To Guides on Community Health Promotion, No. 12. Palo Alto, Calif.: Stanford Health Promotion Resource Center.

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