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

• health status, (b) a clear theory of improvement, and (c) some reasonable ideas about how to reach the entire population; and
• identify key input processes and intermediate outcomes within each performance area.

The workshop concluded with a review of lessons for the committee, beginning with comments on the field model. The field model appears especially useful from a public health perspective. The model facilitates focusing on population effects, and its broad inclusion of disease, well-being, health, and function provides a basis for expanding monitoring systems to include these areas.

The field model also provides a useful basis for addressing the committee's concern for equity in health and how to promote equity in health through a performance monitoring system. The model makes it possible to study equity as it relates to social class, family structure, education, and social networks. The model's treatment of genetics in interrelationship with other determinants and its view of behavior as an intermediate determinant are also helpful. Considering behavior as a product of various factors encourages users of the model to avoid blaming victims. Still needed, however, is better information regarding which determinants are actually amenable to intervention and whether community processes really lead to measurable community outcomes. Ways to measure cooperation are also lacking.

The panel's presentations and discussion illustrated differences among programs in the degree to which goals, performance measurement, and stakeholder roles have been articulated. The discussion also pointed out that community process can be catalyzed by a triggering event. This might be the availability of funding or public outcry when a situation is unacceptable. Different communities will require different approaches to the selection and use of performance indicators. It will be a challenge for the committee to propose a system that satisfies both "cookbook" and "menu" approaches.

Stakeholder identification appears to occur in two parallel tracks based on different responsibilities in some programs. One set of stakeholders is more involved in developing the information infrastructure, while the other set of stakeholders is involved in decision making or policy development. Potential trouble exists if the two groups do not communicate adequately. It was suggested that well-constructed coalitions of stakeholders can "keep the process honest." Ensuring meaningful consumer participation is another challenge shared by the programs, and is a topic that requires more attention. Panelists

were sensitive to the need to listen both to stakeholders who are active participants and to those who are not before reaching conclusions about intervention strategies or performance indicators.

Concern about the potential for harmful use of data provided by performance monitoring was raised. There is a possibility that data could be misused in resource allocation if overly simplistic formulas are applied, and the committee must remain aware of these risks. Communities with multiple needs and few resources might lose funding for doing poorly, or communities that are achieving positive results might be at risk of losing funding if needs are assumed to be met. A community that is addressing a difficult problem may be doing a good job if it can maintain a given level of performance. For some health issues, prevalence of HIV/AIDS infection, for example, finding only a small increase might represent progress over higher increases in the past. It is also important to monitor ''what is going right'' rather than just looking for poor outcomes.

Final comments addressed social change issues. The models described to the committee contribute to the notion that the process of change is as important as the outcome. They also emphasize that the role of each stakeholder in the process is important for the committee to consider.