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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