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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