Improving Health in the Community A Role for Performance Monitoring (1997) / Chapter Skim
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C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)
C Using Performance Monitoring to Improve Community Health: Exploring the Issues (Workshop Summary)
Pages 374-415
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From page 374... ...
The committee is considering the individual and interrelated roles that public health agencies, health care providers in the private sector, and various other stakeholders play in influencing community-wide health; how the performance of those roles can be monitored in a systematic manner; and how a performance monitoring system can foster collaboration among stakeholders and promote improvements in health status for all members of the community. An important task for the committee will be developing prototypical sets of indicators that communities can use to monitor specific health issues and the role that public health agencies, personal health care organizations, and other 1This appendix is an abridged version of a workshop summary published separately as Using Performance Monitoring to Improve Community Health: Exploring the Issues (Institute of Medicine [1996]
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From page 375... ...
The final presentation in this portion of the workshop reviewed the development of measures of public health practice for assessing the performance of local health departments and Illinois's application of such assessments in certification of its local health departments. A set of presentations on Washington State and Seattle–King County included discussions of the state health department's focal role in public health policy; links between the University of Washington School of Public Health and the state's local health departments; the community-oriented approach of the private nonprofit Group Health Cooperative of Puget Sound; efforts to bring a health outcomes perspective to assessments of environmental health activities; the state's voluntary public–private collaboration in the development of health data systems; and an overview of the health assessment and monitoring program in Seattle–King County.
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From page 376... ...
Any effort to propose a model for a performance monitoring system must take into account the social, political, economic, and organizational differences among states and communities, all of which influence capacity and willingness to address community health. An assessment of how well private sector health plans are serving their members and the community is seen by many as an appropriate element of the community monitoring process.
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From page 377... ...
CONNECTING WITH THE COMMUNITY Improving the health of communities requires looking beyond the contributions of medical care and providers of personal health care services. Similarly, measures of community health must be based on a broader population than those who have received medical care or who are members of a particular health plan.
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From page 378... ...
Adapting Health Plan Performance Indicators for the Community3 The Center for the Advancement of Health in Washington, D.C., in connection with the California Wellness Foundation's Health Improvement Initiative, has considered how performance indicators developed for health plans might become a tool for accountability to stakeholders in communities served by health plans (see Sofaer, 1995)
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From page 379... ...
ASSESSING COMMUNITY PUBLIC HEALTH PRACTICE4 Federal, state, and local public health agencies have special responsibilities for protecting and improving community health. The Future of Public Health (IOM, 1988)
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From page 380... ...
included as Objective 8.14 that 90 percent of the population be served by local health departments that are effectively carrying out the core functions of public health. Work is now under way to develop measures of effective public health performance to assess progress toward this Healthy People 2000 objective that states and communities can use to monitor and improve public health practice.
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From page 381... ...
Using Public Health Performance Measurement Information from monitoring public health performance has various applications. At the national level, the measurement tools being developed provide a way to monitor progress toward the Healthy People 2000 objective of having 90 percent of the population served by local health departments effectively carrying out core public health functions.
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From page 382... ...
Discussion by the committee pointed to the importance of state infrastructure for local health department performance and the need to be able to assess state as well as local capacity and performance. In addition, it was emphasized that differences among states in the nature of local health departments can affect which functions can be conducted at the local level and, therefore, their apparent level of "effectiveness." MONITORING AND IMPROVING COMMUNITY HEALTH: A WASHINGTON STATE CASE STUDY Understanding the political, economic, and social systems that influence the determinants of health will be crucial for the committee's consideration of sets of indicators for performance monitoring.
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From page 383... ...
Some activities under way before the legislative changes were emphasizing the value of prevention and the need for partnerships among public, private, and academic health systems. Public Health in Washington State5 Washington's population of about 5 million is served by 33 local health jurisdictions that are independent of the state health department and provide few personal health care services.
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From page 384... ...
The Center has responded to training needs in local health departments with a two-week summer institute and, in collaboration with the state DOH, the local public health community, and several university programs, with a series of training modules that are offered via satellite in seven locations throughout the state. Training needs include: assessment techniques, data analysis, and community organizing.
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From page 385... ...
Several factors were considered in undertaking community programs. Improved community health is expected to lead to improved health for members.
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From page 386... ...
Performance monitoring presents an opportunity to assess individual health care organizations and to encourage efforts such as health promotion rather than care for preventable illness. It may also be possible to monitor health plan partnerships with local health departments and other community groups.
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From page 387... ...
Environmental health directors in the state are working to develop clear and comparable definitions of terms and to address how to collect information that can be useful in efforts to improve community health status. An environmental health addendum has been developed for APEXPH materials for community assessments (Washington State Department of Health, 1993)
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From page 388... ...
Other groups will be producing proposals that focus more on community health measures. Communication between participants with a personal health care perspective and those with a public health perspective has made health care providers more interested in having access to population-based and clinical data.
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From page 389... ...
Other factors for which better measures are needed include stress, social support, and community values. In monitoring community health interventions, information is needed on the nature of the interventions, the targeted recipients (e.g., specific individuals, subpopulations, or the entire community)
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From page 390... ...
Local health departments might benefit from access to additional expertise in making such estimates. Selecting Indicators Specific indicators used in the Seattle–King County assessment process reflect input from sources such as the statewide Community Data Task Force, various constituencies within the county, and the county health department.
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From page 391... ...
Participation promotes community "ownership" of the process and the results. Health departments are generally a resource for essential technical and organizational services for community health assessment.
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From page 392... ...
Some specific areas in which the committee might be helpful were noted: proposing indicators; encouraging the development of indicators for less developed domains such as environmental or social determinants of health; suggesting data standards for defining populations; and outlining processes for involving community stakeholders. ACTIVITIES AT THE NATIONAL LEVEL A variety of federal agencies and private sector organizations have programs that address monitoring and improving community health.
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From page 393... ...
A menu of health status objectives from which states can choose is to be developed in a collaborative effort organized by DHHS. Several factors will be considered in selecting PPG objectives: links to Healthy People 2000 (USDHHS, 1991)
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From page 394... ...
Centers for Disease Control and Prevention: Activities in Managed Care16 Public health agencies have generally been responsible for broad community health needs but in many communities have also been providing personal health services. In the private sector, the growth of managed care organizations (MCOs)
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From page 395... ...
. A particular focus is the set of 18 health status indicators selected in response to Healthy People 2000 Objective 22.1, which calls for "a set of health status indicators appropriate for Federal, State, and local health agencies," and the summary indicator of years of healthy life (CDC, 1991; Erickson et al., 1995)
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From page 396... ...
Part one is an organizational capacity assessment to identify strengths and weaknesses in a health department and develop a responsive action plan. The second part guides health departments in developing a community health planning committee that can identify health problems of concern to the community and mobilize the community to ad 18This section is based on a presentation by Claude Hall.
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From page 397... ...
, which provides tools to facilitate use of APEXPH. NACCHO recently published a profile of local health departments that presents, in the aggregate, information on their organization, resources, and activities (NACCHO, 1995b)
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From page 398... ...
It was suggested that health plans could be gathering more information relevant to community health than they are currently asked to do, but NCQA questions the extent to which HEDIS and health plans should be expected to collect community health data. Joint Commission on Accreditation of Healthcare Organizations22 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
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From page 399... ...
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 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.
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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?
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As one step toward greater clarity, the committee changed the name of the study from "Public Health Performance Monitoring" to "Using Performance Monitoring to Improve Community Health." REFERENCES APHA (American Public Health Association) , Association of Schools of Public Health, Association of State and Territorial Health Officials, National Associa tion of County Health Officials, United States Conference of Local Health Officers, Department of Health and Human Services, Public Health Service, Centers for Disease Control.
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1994. Analyzing Organizational Practices in Local Health Departments.
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1994. Public Health Improvement Plan.
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From page 404... ...
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 healthrelated functions.
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From page 405... ...
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 system 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.
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From page 406... ...
Healthy People 2000: 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)
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From page 407... ...
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.
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From page 408... ...
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.
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From page 409... ...
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.
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From page 410... ...
• 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.
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SESSION III: Public Health Practice and Process Measurement in the Community Bernard Turnock Clinical Professor of Community Health Sciences, University of Illinois at Chicago 12:00 p.m. Lunch
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Overview Kristine Gebbie Faculty, Columbia University School of Nursing Former Commissioner of Health, Washington Member, IOM Board on Health Promotion and Disease Prevention 1:30 p.m. Academic Health and Local Health Departments James Gale Professor, University of Washington School of Public Health, Health Officer, Kittitas County, Washington Member, IOM Committee on Public Health Performance Monitoring 1:50 p.m.
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From page 413... ...
SESSION VI: National Activities: Other Involvement with Performance Monitoring and Reaction to Committee Draft Vision Facilitator: Alan Cross Linda Demlo Acting Director, Center for Quality Measurement and Improvement, Agency for Health Care Policy and Research Randy Gordon Associate Director for Managed Care, Centers for Disease Control and Prevention Claude Hall Director, Model Standards Project, American Public Health Association Roz Lasker Deputy Assistant Secretary for Health Policy Development, Office of the Assistant Secretary for Health Nancy Rawding Executive Director, National Association of County and City Health Officials Cary Sennett Vice President, National Committee for Quality Assurance Margaret VanAmringe Washington Office Director, Joint Commission on Accreditation of Healthcare Organizations Ronald Wilson Special Assistant, Office of Analysis, Epidemiology, and Health Promotion, National Center for Health Statistics 12:00 p.m. Committee Challenge, Wrap Up and Thank You Facilitator: Bobbie Berkowitz 12:30 p.m.
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BERNARD TURNOCK, Clinical Professor of Community Health Sciences, University of Illinois at Chicago MARGARET VANAMRINGE, Director of the Washington Office, Joint Commission on Accreditation of Healthcare Organizations, Washington, D.C. ELIZABETH WARD, Assistant Secretary, Epidemiology and Health Statistics, Washington State Department of Health, Olympia, Washington RONALD WILSON, Special Assistant, Office of Analysis, Epidemiology and Health Promotion, National Center for Health Statistics, Hyattsville, Maryland Invited Guests CYNTHIA ABEL, Program Officer, Division of Health Promotion and Disease Prevention, Institute of Medicine, Washington, D.C.
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From page 415... ...
NANCY KAUFMAN, Vice President, The Robert Wood Johnson Foundation, Princeton, New Jersey JORDAN RICHLAND, Executive Director, Partnership for Prevention, Washington, D.C. JOSEPH THOMPSON, Luther Terry Fellow, Office of Disease Prevention and Health Promotion, U.S.
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