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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