A recent IOM report, Improving Health in the Community,25 proposes ways of bridging the gap between national goals and community action and identifying specific organizations or groups at the community level accountable for making progress toward those goals. The general approach discussed in the report is embodied in the Community Health Improvement Process (CHIP). CHIP applies the tools used to monitor performance. To promote the achievement of health improvement goals, the approach entails (a) specifying goals, (b) developing a strategy to achieve them, (c) identifying and implementing local interventions that can be monitored by quantitative indicators, and then (d) collecting and assessing performance data for the specific accountable entities at the community level to evaluate the effectiveness of the intervention strategy and the contributions of the specific accountable entities in the community. The accountable entities will vary among communities, as will the relative priorities of the goals and the resources available to attain those goals.

The CHIP approach might be adapted for use at the national level as well. National health improvement goals might be translated into intervention strategies that federal agencies and a variety of national organizations might be expected to act on and for which performance indicators might be developed and monitored. Such activities at the national level might help shape related efforts at the state and local levels. The approach is described at greater length, with its theoretical underpinning and with specific consideration of tobacco control issues, in a separate background paper prepared for the board by Michael Stoto and Jane Durch of IOM (available on-line at http://www2.nas.edu/cancerbd/226e.html).

Three elements are central to the IOM CHIP model: (1) a broad view of health as a product of the interaction of many factors; (2) recognition that protecting and improving health is a shared responsibility of many entities, each of which needs to be accountable for its activities; and (3) a performance monitoring framework, in which sets of actionable measures are tied to specific entities that can help to ensure the necessary accountability. Accountability is a concern because responsibility diffused among many entities can easily be ignored or abandoned. This approach also points to the importance of interventions that focus not only on individuals but also on collective actions such as the adoption of policies to limit smoking in workplaces or restaurants or the enforcement of laws prohibiting the sale of tobacco products to persons under age 18. In extending the CHIP concept to the national level, there may be opportunities to focus on interventions that target communities and organizations rather than individuals.

A well-chosen set of performance measures could help to reinforce a balanced national and local tobacco control effort. The CHIP approach calls for the use of sets of indicators to make meaningful assessments of overall performance because health issues have many dimensions and can be addressed by various sectors. These sets of indicators should cover critical features of a health improvement effort. They should, however, remain selective; too many details can obscure the broader picture. Indicators must be carefully selected to provide insight into the progress that has been achieved. For an issue such as tobacco control, for which changes in health outcomes such as a reduction in lung cancer deaths will not be observable in the near term, the set of indicators should balance measures of shorter-term gains (e.g., reductions in smoking prevalence or sales of tobacco products to minors) and more fundamental longer-term changes in health (e.g., reductions

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