Using Performance Monitoring to Improve Community Health: Exploring the Issues (1996)

(August 1, 1995)

The Institute of Medicine (IOM) Committee on Using Performance Monitoring to Improve Community Health intends to consider, from a systems perspective, the roles that the public health and personal health care systems and other stakeholders play in influencing community-wide health, how their performance of those roles can be monitored, and how a “public health performance monitoring” (PHPM) system can be used to foster collaboration among these sectors and promote improvements in community health. The committee's goal is to develop prototypical sets of indicators for specific public health concerns that communities can use to monitor the performance of public health agencies, personal health care organizations, and other entities with a stake in these matters. The committee will collect and analyze information on existing and planned systems related to public health performance monitoring, confer with experts in the field individually and through workshops, and prepare a written report that sets out principles of public health performance monitoring from a systems perspective, and illustrates these principles in a practical manner.

For PHPM to serve the core functions of public health—assessment, policy, and assurance—the committee foresees a need for an infrastructure for public health information. This information infrastructure would need to monitor diverse phenomena in the many sectors that contribute to the health of populations, including clinical care, environmental services, individual and public education, community social services, and public policy promoting behavioral change, among others. It also would need to employ measurement strategies far more sophisticated than those in current use; provide information on the health status of a community, including threats to its future health; inform decisions about how to improve the health of the public; and document change in community health and in performance of health-related functions. In such a

PHPM system, individuals and programs concerned with the health of the public could coordinate data collection, trend and subgroup analyses, decision support, and program evaluation, successfully serving many organizational entities.

To guide its deliberations, the committee has framed an initial vision for PHPM. To affirm the potential future reality of this vision, the committee intends to take significant steps toward its initial specification. A central focus will be to

• Describe how to use a PHPM system to improve the public's health by identifying the range of actors that can affect community health, monitoring the extent to which their actions make a constructive contribution to the health of the community, and promoting policy development and collaboration between public and private sector entities that are responsible for components of the larger health enterprise of the nation.

To further develop its vision for PHPM, the committee aims to

• Specify an organizational and policy context for public health performance monitoring that unites the interests and authorities of the local, state, and national public and private sector entities that should be held accountable for the public's health;

• Advance a series of definitions to guide the development of a PHPM system;

• Document and critique the current state of the art in PHPM;

• Recommend innovations and priorities in the development of new measurement and data management systems to serve comprehensive PHPM;

• Provide detailed examples of several recommended performance indicator sets, illustrating the integration of data from multiple sources to assess various dimensions of the state of the public's health in relation to key health problems or risks. These dimensions would include (a) individual health status, (b) behavioral, biological, and environmental risk factors, and (c) the availability and use of individual- and population-focused interventions known to improve health;

• Recommend a set of performance indicators that would capture information on the most important health problems faced by the population so as to have a monitoring system that will continually assess the health status of the public;

• Specify recommended characteristics of the structure, resources, and reporting relationships among participants in the PHPM system; provide guidance on how public and private-sector entities can work jointly to develop a PHPM that is of use to the organizations as well as to the public's health; and

• Identify ways in which such a PHPM system can be continuously refined to accommodate emerging priorities in the nation's health.

Performance measures have been used in assessing health status, personal health care services, as well as population-based public health activities with increasing sophistication for many years. Today, performance measures are gathered and used by a wide variety of sources: academic researchers, census takers, hospitals, public health and safety agencies, drug companies, insurance companies, employers and other health care purchasers, quality assurers, clinicians, and educators. Uses include resource allocation, monitoring of trends, cost containment, management, quality assurance, and accreditation.

In the personal health care area, for instance, HEDIS: The Health Plan Employer Data and Information Set, produced by the National Committee for Quality Assurance, is a defined set of performance measures used by employers and HMOs to compare health plans on the basis of quality, access and patient satisfaction, delivery of preventive services, membership and utilization, financing, and descriptive management information. The Joint Commission on Accreditation of Healthcare Organizations has used standards, the focus of which have in recent years been in keeping with a broader philosophy of performance monitoring.

Performance measurement has also been developed in public health. Healthy People 2000: The National Health Promotion and Disease Prevention Objectives, produced by the Public Health Service with the collaboration of the Institute of Medicine, outlines 22 categories of measurable health objectives in health status, risk reduction, and services and protection, that is, both process and outcome measures. The objectives process has been implemented by a number of states and local health departments, in some cases using the tools provided by Healthy Communities 2000 and earlier editions of the Model Standards, which is run with American Public Health Association (APHA) coordination. Healthy Communities 2000 helps states and communities adapt Healthy People 2000 objectives to their specific needs and frame the links between health outcomes and public health structure and process.

“America's Public Health Report Card,” prepared by APHA, and APEXPH: Assessment Protocol for Excellence in Public Health, developed by the National Association of County Health Officials and others, illustrate other approaches. APEX, for example, offers local health officers a workbook for conducting an assessment of the strengths and weaknesses of their department. It also provides health departments with guidance on working with others in the community to assess and respond to community health needs. CDC's Public Health Practice Program Office (PHPPO) is leading efforts to respond to objective 8.14 in Healthy People 2000, which calls for measuring the extent of effective public health practice at the local level. This work derives not only from Healthy People 2000 and Healthy Communities 2000, but also from

definitions of public health core functions in the IOM report The Future of Public Health and CDC's earlier work on “public health practices.”

Taken together, these activities provide a good foundation for monitoring key health outcomes and public health practices. What is needed, and will be the centerpiece of the IOM study, is a way to use the available systems and others to assess how well the providers of population-based core public health services, in conjunction with providers of personal health services, perform and interact in protecting and improving the health of communities.

If public health performance monitoring is to develop into an important tool used by many and varied entities, an ongoing conceptual development process is critical. Each user will face its own decisions, look at a health question from its own vantage-point, and scrutinize particular opportunities to influence the health of the public it serves. Not only will different users have different priorities, they will have different budgets, time frames, and values, all influencing the balance of measures to be chosen. Ongoing changes in emerging technologies in clinical medicine, improving informatics, new biophysical technology, and evolutions in marketing, governance, and benefits coverage, along with redefined values, will compel the PHPM system to anticipate and help shape, as well as respond to, changes in health and health care in the United States. For these reasons, the committee will not offer a full prescriptive set of PHPM indicators, but will develop a framework for such a system, and practical examples of its application in about ten critical areas.

In its report, the committee will illustrate the process it recommends for the development of a PHPM system, using examples suitable for diverse potential users and situations. Those seeking to use performance monitoring could include local, state, or federal government public health agencies; employers; private health industries; community organizations; budget analysts; accrediting organizations; health-related workforce planners and educators; and research agenda setters. Specific community health concerns to be addressed might be selected from broad categories such as environmental toxins, infectious disease, injury control, quality of life in chronic disease, mental illness, and vulnerable populations (such as children, the elderly, and those with financial or geographic access difficulties).

Selection of these specific examples will depend on various considerations including the extent to which meaningful health improvements can be promoted by appropriate and measurable actions taken by identifiable parties within a community. The appropriate actions and actors to monitor are likely to vary across communities because of factors such as differences in the organization of

the public and private health sectors and in the political, economic, and cultural contexts.

For each specific health concern chosen for detailed consideration, the committee will suggest a set of indicators that, taken together, can be used to monitor health status in relation to actions that should have an influence on it. Indicators should be selected so as to promote constructive actions that are expected to have a positive influence on community health. For example, monitoring smoking rates among health plan members might encourage a plan to avoid enrolling smokers rather than to offer smoking cessation programs. The committee also will identify some of the information sources for particular indicators and will address methods for presenting and analyzing that information. An example might be a set of indicators on tobacco and health that can be used to monitor health effects associated with tobacco use and factors that can influence the use of tobacco. The indicators could include elements such as:

• traditional vital statistics (e.g., lung cancer and heart disease mortality and morbidity rates),

• results from behavioral risk and attitude surveys,

• use rates for tobacco and other substances (e.g., excise taxes collected on tobacco products, sales figures, survey data),

• quit rates,

• smoking cessation program availability (location, price, enrollment),

• business policy actions (e.g., advertising budgets and strategies),

• local government actions (e.g., regulation of tobacco use in public places),

• youth access to tobacco products,

• economic costs of tobacco use (e.g., morbidity, mortality, work loss), and

• the implementation of public and private tobacco control programs.

To achieve its goals, the committee will prepare a book-length report that would introduce a vision of a PHPM system that can monitor and improve the production of health in communities; clarify the vision and its value to stakeholders, including the public; and document the current reality of scientific cultures, political environments, gaps in knowledge in our current understanding of health and its determinants. The report will recommend guiding principles and who can do what to move us toward the vision.

The report will include examples that demonstrate how a PHPM system can be used by a community to characterize and monitor the actions that the

agencies, organizations, individuals, and other entities in a community could be expected to take to contribute to health improvement, and to apply the information generated to encourage entities to take those actions that promote improvements in the community's health. These examples will demonstrate tools that communities can use to address other health concerns.

Sections in the report (as it is currently planned) will address:

• The committee's vision, and PHPM definitions and concepts.

• The current reality of the political and cultural environment in which PHPM must take place, including the need for better links between medical care and public health; differences of language, culture, conflicting goals and interests; many stakeholders with different needs/perceptions; diversity and complexity; and problems with accountability.

• Health and its biologic and social determinants, including basic questions such as definition of health and ways to measure it in the determinants of health; the interconnectedness of health, public, and social systems.

• Health systems, including capacities of well-functioning health systems such as problem identification and monitoring; relations between public health systems, care providers, and so on; capacities for measuring health system effectiveness; well-functioning processes of change and improvement and feedback.

• Detailed examples, as suggested above, of indicator sets that can be used for public health performance monitoring directed toward specific health concerns.

• Detailed examples of public health performance monitoring as it currently exists or can exist in particular states or localities; each would focus on the system as a whole, how problems are identified, and how specific problems are managed.

• Recommendations regarding guiding principles and operationalizing the vision.