community assessment, and collaborative community-oriented quality improvement.

JCAHO also is addressing the development of indicators to monitor how well performance conforms with Joint Commission standards and to provide health care organizations with information needed for quality improvement efforts. The Indicator Measurement System (IM System), originally developed for hospitals, is being expanded to include other kinds of health care organizations and a broader range of indicators covering issues such as access to and satisfaction with care as well as clinical quality of care.

Rather than develop all additional indicators de novo, JCAHO will adopt some that are already available from other sources to address areas of care including substance abuse, mental health, cancer, diabetes, and pregnancy. Of about 800 indicators received from 24 organizations, about half are being evaluated for inclusion in the IM System for managed care networks. In addition, JCAHO hopes to collaborate with other groups to assemble a collection of other indicator systems from which health care organizations can choose. It will be essential that these other systems be sufficiently well developed to provide a framework for ongoing structured data collection and reporting that generates information useful for quality improvement activities. These indicator systems will need mechanisms to deal with issues such as standard data sources, case-mix adjustment, and consolidation of information from multiple sources (e.g., on immunizations provided within a health care network and at a public health clinic). JCAHO anticipates increasing its expectations for these systems over time but wants to begin offering them now as acceptable alternatives to the IM System rather than continue to wait for “perfect” systems.

COMMITTEE COMMENTS ON PRESENTATIONS AND DISCUSSION

The workshop discussions made a valuable contribution to the committee 's thinking about the general concept of health-related performance monitoring and about the specific tasks to be addressed in this study. They helped demonstrate the complexity of the issues before the committee and the need for further examination of many of the elements of the committee's vision for a performance monitoring system that can promote improvements in community health.

A phrase taken from the statement of the committee's aims, “examine public health performance monitoring from a systems perspective, ” when considered in light of the workshop discussions, contains several key terms requiring clarification. “Public” should be understood to mean the general population, the inclusive denominator for the measurement process. For some measures, the population of interest may vary— residents of a community or



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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary community assessment, and collaborative community-oriented quality improvement. JCAHO also is addressing the development of indicators to monitor how well performance conforms with Joint Commission standards and to provide health care organizations with information needed for quality improvement efforts. The Indicator Measurement System (IM System), originally developed for hospitals, is being expanded to include other kinds of health care organizations and a broader range of indicators covering issues such as access to and satisfaction with care as well as clinical quality of care. Rather than develop all additional indicators de novo, JCAHO will adopt some that are already available from other sources to address areas of care including substance abuse, mental health, cancer, diabetes, and pregnancy. Of about 800 indicators received from 24 organizations, about half are being evaluated for inclusion in the IM System for managed care networks. In addition, JCAHO hopes to collaborate with other groups to assemble a collection of other indicator systems from which health care organizations can choose. It will be essential that these other systems be sufficiently well developed to provide a framework for ongoing structured data collection and reporting that generates information useful for quality improvement activities. These indicator systems will need mechanisms to deal with issues such as standard data sources, case-mix adjustment, and consolidation of information from multiple sources (e.g., on immunizations provided within a health care network and at a public health clinic). JCAHO anticipates increasing its expectations for these systems over time but wants to begin offering them now as acceptable alternatives to the IM System rather than continue to wait for “perfect” systems. COMMITTEE COMMENTS ON PRESENTATIONS AND DISCUSSION The workshop discussions made a valuable contribution to the committee 's thinking about the general concept of health-related performance monitoring and about the specific tasks to be addressed in this study. They helped demonstrate the complexity of the issues before the committee and the need for further examination of many of the elements of the committee's vision for a performance monitoring system that can promote improvements in community health. A phrase taken from the statement of the committee's aims, “examine public health performance monitoring from a systems perspective, ” when considered in light of the workshop discussions, contains several key terms requiring clarification. “Public” should be understood to mean the general population, the inclusive denominator for the measurement process. For some measures, the population of interest may vary— residents of a community or

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary state, employees at a worksite—but should be defined as comprehensively as possible. Addressing “health” raises concerns about where boundaries can be drawn on the continuum that ranges from obviously relevant morbidity and mortality to more complex issues of functional status and social constructs of well-being. A distinction must also be made between an individual's health and population-based health. Use of “public health” is intended to refer to the broad notion of the public's health but can be misconstrued as referring only to matters related to public health agencies. Trying to understand “performance” leads to questions about how to link it to either resource inputs or health outcomes. “Monitoring” emerges as an ongoing process of collecting, reviewing, and refining information. Finally, a “systems perspective ” suggests looking for a way to see the constructive connections that could exist among activities and organizations. The committee will need to consider how those connections can be translated into a system, which might be seen as a framework within which activities take place. The workshop discussions pointed to important issues that need further attention from the committee and others. The need to strengthen the evidence base for the health benefit—the efficacy—of many population-based health activities is of particular concern. It may not be possible, however, to identify “the” proper response to some health problems (e.g., gun-related injuries) because circumstances and acceptable responses vary across communities (e.g., gun control versus gun safety). The concept of community will require further elaboration as well. Issues needing attention include determining who the community actors are, or should be, understanding how they might be expected to change, identifying strategies that can be used to promote change in a specific community, and addressing the health needs of communities not defined by geography. The workshop also gave the committee an opportunity to learn about a substantial and diverse array of activities related to performance monitoring that are already in operation. There is, however, too little coordination among those activities. A clear gap exists between the current outcomes and performance measurement work being done in many areas of medical care and that being done for various aspects of public health. Alone, no one entity has adequate data to determine what is needed to protect and improve health in a community. The diverse health-related data gathering and analysis activities in many communities are generally not integrated into a coherent system of sufficient quality and scope to support performance monitoring as envisioned by the committee. The analogy of a patchwork quilt was used to describe the committee's task of exploring how existing activities might be brought together in the most effective manner. It will be necessary to learn what factors promote integration and how the committee can contribute to achieving a good fit in ways that avoid duplication and build on the best elements of each activity. It should be possible to avoid reinventing systems that exist, but the committee

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary needs to identify areas that are important for achieving health improvement that none of the existing systems address. The committee will have to consider not only the intellectual task of understanding the pieces that make up a performance monitoring system but also the practical realities of the organizational, social, and political context in which such a system will function. The committee will need to understand who the stakeholders are, what concerns they have, and how to promote their collaboration and commitment to making a system work. Within a community, the relationships may be complex: the organizational entity assuring that data are gathered may be different from the entity analyzing the data, which in turn may be different from the entity that has responsibility for developing or implementing changes. In proposing how a performance monitoring system might work, the committee must take into account the political, economic, and organizational differences among states and communities. The committee's task is complicated further by the important changes occurring in the organization and delivery of public health and health care services, which may reduce the ability or willingness of a broad range of stakeholders to address community-wide health issues. On some issues, such as improving linkages among health sectors and with areas outside the traditional scope of health (e.g., criminal justice, education, housing), the workshop presentations suggested that opportunities exist but that progress has been limited so far. Identifying shared interests that can promote collaboration in meeting health needs will be important. Of concern to the committee, and implicit in many of the presentations, is understanding how to achieve change in communities. What creates “readiness” or incentives to make the changes that address health problems in a collaborative way? What “levers” are available to promote constructive change at the federal, state, and local levels and in public and private sector organizations? The committee also faces the question of how a performance monitoring system fits into a process of community change. One view is that having data from such a system promotes change, but others might argue that change is needed to create a setting in which a performance monitoring system can operate. Because performance monitoring systems will exist in an environment characterized by change, another question emerges for the committee to consider: What kind of system will be able to function successfully now and also be able to adapt to new circumstances? It was suggested that the committee needs to consider what principles can serve as a guide toward its vision of a performance monitoring system and what some of the practical steps are that could be taken to move toward achieving that vision. The presentations making up the Washington State case study illustrated some of the possible accomplishments at the state and local levels and pointed out some of the obstacles that exist. The diversity of circumstances

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary evident in the workshop presentations means that there will, of necessity, be different approaches to performance monitoring in different places. The committee may want to consider how its proposed performance monitoring system might be tested in a few settings so that refinements based on practical experience could be made before addressing a broader, and perhaps more challenging, audience. As a result of the discussions throughout the workshop, the committee recognized the critical importance of presenting its ideas in a way that makes them understandable to the variety of audiences that need to participate in efforts to improve community health. A particular concern is ensuring that the phrase “public health” is understood in its broadest sense. As one step toward greater clarity, the committee has changed the name of the study from “Public Health Performance Monitoring” to “Using Performance Monitoring to Improve Community Health.”