public service groups); those with responsibility for accomplishing specific tasks are accountable to the community for their performance.2

Several assumptions underlie the committee's approach to performance monitoring. First, it is increasingly necessary to use resources efficiently, that is, to accomplish tasks with a minimum of waste. Performance monitoring is expected to facilitate efficient approaches to improving the health of communities at a population level. Second, a performance monitoring system should have a broad enough perspective to monitor diverse factors that influence a community's health, including ones that may not appear obviously health related. Third, a wide range of actors share a stake in community health; thus, social action and changes that involve many sectors of the community are necessary. Finally, special attention to vulnerable populations is important, because equity is valued in community health.

The application of performance monitoring presents problems at the current level of knowledge and infrastructure. Although tools for indicator development exist, the conditions for creating operational monitoring systems at the community level may not. Furthermore, measurement strategies for an array of health issues are not universally available, and measures that are available may not always be applicable at the community level. In addition, most information systems are not yet able to support the identification and analysis of health problems and to track interventions.

A central task for the committee is the development of indicators suitable for community-based performance monitoring.3 Ideally, performance indicators measure states or critical processes that are potentially alterable and thought to have a demonstrable relationship to health outcomes. Those indicators may be measures of capacity, resources, processes, or actual health outcomes. Committee discussions suggest that indicator selection should be based on a


The committee's approach to performance monitoring relies on both the public health "core functions" of assessment and assurance (IOM, 1988) and the health care activities related to quality assessment, assurance, and improvement (see IOM, 1990). From a public health perspective, assessment is the regular collection, analysis, and dissemination of information on the health of the community. Assurance refers to a governmental responsibility to ensure that services necessary to achieve agreed upon goals are provided. Quality assessment refers to measurement of processes and outcomes of health care and their comparison against a standard. Quality assurance employs such measurement within the context of a broader set of activities that includes steps to identify and correct problems. Quality improvement uses continuous measurement and analysis of processes and outcomes not only to address problems but also to maintain and enhance good performance. The health improvement activities envisioned by the committee combine a responsibility to the community for achieving health goals with techniques like those used in quality improvement.


The indicators proposed by the committee will appear in the final report for this study.

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