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