their activities. If available, however, such tools may contribute to performance monitoring activities in the community. Important measures include units of services delivered, costs of services, proportion of need met, percentage of resources used to meet objectives, and impact. Community members can provide feedback, measuring how well individuals external to an organization rate the organization's efforts. In addition, an organization should consider how well its programs and services compare with "best practices." It was noted that efforts to identify best practice in developing and using community report cards are under way.

Performance monitoring provides an opportunity for a community to define and articulate expectations for organizations' contributions to the population's health. Although organizations might disagree with the appropriateness of the expectations, a useful dialogue may ensue. It was suggested that communities may want to focus special attention on expectations regarding managed care organizations (MCOs) and business. MCOs have improved provider education efforts and information tools such as clinical records, but "community" is often defined as their enrollees. Historically, MCOs have not considered the entire community or public health as their area of concern. A community expectation that part of their corporate and social responsibility is the health of the entire local population could encourage their broader involvement in public health activities.

Businesses, including MCOs, that have strong historical ties with a city or region may have greater interest in local health issues. However, as corporations expand to multiple regions, they may be less involved in the local communities where they have a presence. It was suggested that larger corporations operating in many locations should be encouraged to be involved in those communities. At the same time, smaller businesses with strong local bases should be educated and encouraged to become involved in community health efforts.

The presentation concluded with mention of another framework for assessing the community and health that translates the determinants of the field model into community terms (see Figure 2). Community social and physical environments are affected by cultural, political, policy, and economic systems and in turn, influence community response, activation, and social support, and ultimately community outcomes including social behaviors, community health, and quality of life (Patrick and Wickizer, 1995). Therefore, performance monitoring might also benefit from attention to the underlying cultural, political, and economic forces represented in this framework.



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