resulted in the development of "report cards" by some individual health plans and in a variety of nationally used and proposed health care indicator sets (e.g., Nadzam et al., 1993; NCQA, 1993, 1996a; AMBHA, 1995; FAcct, 1995). Individually, many health care organizations are monitoring performance for their internal quality improvement purposes and for tracking community benefit activities.

A focus on performance and outcomes also is central to ideas on "reinventing government" (Osborne and Gaebler, 1992; Gore, 1993; Hatry et al., 1994). The Government Performance and Results Act, for example, requires federal agencies to develop annual performance plans and to identify measures to assess progress (GAO, 1996). The proposals to implement PPGs for several health-related block grants would apply a similar approach to state grantees (USDHHS, no date). Some observers, however, caution against an overreliance on measurement in managing government activities, suggesting that many important tasks of government cannot be adequately quantified and that even if measurable may not be adequately insulated from political pressures (Mintzberg, 1996).

ADVANCING THE PROCESS

The process proposed by the committee reflects the need to combine features of these various activities to produce both a community-wide perspective and the performance measures that support accountability and inform further improvements. The current health planning and health assessment models provide a comprehensive community perspective but generally put less emphasis on the linkage between performance monitoring and stakeholder accountability than either the problem identification and prioritization cycle or the analysis and implementation cycle of the proposed CHIP. The quality improvement and performance measurement activities that have developed in the personal health care sector bring accountability for performance to the fore explicitly. They are, however, generally applied to specific institutions or health plan services for their members, not to activities of many entities responding to the needs of the entire population of a community.

Both community-wide and organization-specific performance measurement processes are needed to improve the health of the general population. Applying the field model perspective encourages consideration of the diversity of opportunities and agents, both inside and outside the usual "health" setting, that can con-



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