Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience (1996)

Issues common to the five programs discussed with the committee are availability of resources, leadership, training, and the development of organizational knowledge. The balance between data-driven and community-driven processes varies among the five programs, as does the degree of community involvement in defining problems and interventions. All use performance indicators in some form.

Recognizing that health improvement activities and performance monitoring imply the need for change in communities, the committee sought to explore some of the theories of social change and how they might relate specifically to health and health care. It was noted that change is ubiquitous today in health care systems, health care policy, and social policy and is occurring in multiple dimensions. Emphasis is shifting from individual health to population-based health; from tertiary to primary care; from preventive care to health promotion. Tension between controlling costs and improving health complicates change in all dimensions.

Change is not linear. It occurs in a specific context and is subject to complicated interactions. Change is a process of transition; therefore, it is fruitful to study both the change process and its outcome. To determine whether an outcome is causally related to a particular intervention, it is necessary to study the process of change linking the intervention and the outcome. The suggestion was made that natural experiments provide unique opportunities to study change and deserve more scrutiny than they currently receive.

The committee was reminded that people frequently resist change and that change can both arise from and contribute to conflict and tension. Although admittedly uncomfortable, conflict and tension may be necessary prerequisites for constructive change.

Three theoretical constructs that can be used in formulating models of change were noted. Structural functionalism is a positivist approach and is consistent with an epidemiologic orientation. Conflict theory views change as subjective and value laden. Its naturalistic approach parallels community development and participatory action orientations. Symbolic interactionism

involves developing consensus to produce change (Thompson and Kinne, 1990).

Change at the individual level is described by several models. The "stages of change" model was developed to describe smoking cessation (Prochaska and DiClemente, 1986). Readiness for change progresses through stages of precontemplation, contemplation, action, and maintenance. For maximum impact, health interventions are chosen with attention to the individual's stage of readiness.

The Health Belief Model views behavioral change as the result of "triggers" (Rosenstock et al., 1988). Beliefs about susceptibility, severity, benefits of treatment, and barriers to treatment contribute to individuals' willingness to change their behavior. The committee was told that this concept, along with other models of behavioral change, may also be important in studying the change process at an organizational level.

An organizational model of change described by Lewin (1976) is based on a three-stage process that includes "unfreezing" the old behavior, cognitive recognition of the need for a new behavior, and "refreezing" the new behavior. This description is accurate for many organizational change processes. In health care, however, change is currently so rapid that behavior is in a seemingly constant state of unfreezing and refreezing.

Other models also describe organizational change as a staged process (Beckhard and Harris, 1987; Bridges, 1980). Thompson and Kinne (1990) offer a community development model of change that considers change on a continuum from individual to community. The PRECEDE–PROCEED model developed by Green and Kreuter (1991) is also frequently used in health promotion. It approaches change through factors that are grouped as predisposing, enabling, or reinforcing.

Both initiating performance monitoring and responding to the problems identified by performance monitoring systems require changes in the community and on the part of various stakeholders. Alberta, Canada, provides an example of the change process in health care.

Several tensions are influencing health care: individual versus population health; treatment of illness versus health promotion; meeting health needs versus

managing health care costs; traditional versus new organizational models; current social conditions versus societal goals; and maintaining the status quo versus shifting paradigms (Casebeer and Hannah, 1995). Regionalization of the health care system in the province of Alberta constitutes a significant change in the arrangements for managing and providing health services. The change is largely an attempt to control increased health care spending, which grew from 20 to 32 percent of the provincial government's budget between 1980–1981 and 1993–1994, and to alter the orientation of health care provision (managing the system regionally and shifting to a population-based, community-based, health-promoting focus for care).

A study of change in health care and health policy identifies processes of change used by managers, as well as expected and actual health outcomes (Casebeer, 1996). Managers have suggested that successful change depends on the development of structures, processes, and outcomes that encourage the system to change in positive and sustainable ways.

With regard to structures, these managers are attempting to work with

• new and broader governance roles;
• leaner, flatter, more horizontal management of the system;
• new working arrangements for health care providers and managers; and
• new participatory roles for communities.

In relation to process issues, managers emphasized several critical aspects of change:

• the importance of sustaining political will;
• the pace of change;
• the capacity for shifting resources;
• the need for a renewed commitment to positive change;
• improved communication capabilities;
• better information;
• effective planning; and
• time for learning and adjusting.

Managers articulated a range of hopes and concerns in relation to short-term and long-term outcomes. For example, they expect that new management structures and savings would be short-term outcomes, new ways of developing services for better information would be medium-term outcomes, and improved services and health status would be long-term outcomes.

Gaining a better understanding of health care change such as that taking place in Alberta will require additional longitudinal and comparative experience as well as targeted research.