Improving Health in the Community A Role for Performance Monitoring (1997) / Chapter Skim
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D Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience (Workshop Summary)
D Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience (Workshop Summary)
Pages 416-451
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Committee on Using Performance Monitoring to Improve Commu 1This appendix is a workshop summary that has been published separately as Using Performance Monitoring to Improve Community Health: Conceptual Framework and Community Experience (Institute of Medicine [1996]
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In particular, the committee was asked to consider the roles that public health and personal health care systems and other stakeholders play in influencing community-wide health, how their performance in connection with health improvement goals can be monitored, and how a performance monitoring system can be used to foster collaboration among these sectors and promote improvements in community health. The committee brought together expertise in state and local health departments, epidemiology, public health indicators, health data, environmental health, adult and pediatric clinical medicine, managed care, community health and consumer interests, quality assessment, health services research, and employer concerns.
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Performance monitoring should promote health improvement in a context of shared responsibility and accountability for achieving desired outcomes. Many parties within a community share responsibility for health (e.g., consumers, health care providers, businesses, government agencies, public service groups)
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Finally, special attention to vulnerable populations is important, because equity is valued in community health. The application of performance monitoring presents problems at the current level of knowledge and infrastructure.
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They are affected by separate but overlapping factors, and therefore, indicators selected to monitor health improvement programs may need to differ depending on which outcome is of primary interest. The model also reinforces the interrelatedness of many factors.
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Social Environment Among the elements of the social environment that have been linked to health are family structure, the educational system, social networks, social class, work setting, and level of prosperity. Family structure, for example, is known to affect children's physical and mental health.
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(1987) demonstrated a clear relationship between social class (based on job classification)
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It is shaped by many forces, particularly the social and physical environments and genetic endowment, as previously described. Behaviors related to health care, such as adherence to treatment regimens, are influenced by these forces as are behaviors that directly influence health, such as smoking.
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The greatest share of this gain from health care can be attributed to diagnosis and treatment of coronary heart disease, which contributes 1 to 2 of these additional years of life. Linking the Determinants According to the presenter, the Evans and Stoddart field model helps in conceptualizing factors affecting health.
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For example, if adolescents' sense of well-being can be improved by reducing their feelings of alienation and hopelessness, can unintended pregnancies, alcohol and other drug use, crime, and the school dropout rate all be reduced? A multidimensional approach would be required, focusing on education, social and community involvement, family preservation, and improved social networks for teens and
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It is, however, consistent with the field model and may provide expanded opportunities for performance monitoring and improving the community's health. The variety of ways in which community can be defined, such as geography, politics, or social networks, was also noted (Patrick and Wickizer, 1995)
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Are these institutions educating the community about the problems and their responses? Although organizations themselves can benefit from internal monitoring systems to determine their efficiency in resource utilization and whether desired outcomes are being achieved, they often lack the tools to adequately monitor their activities.
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. Community social and physical environments are affected by cultural, political, policy, and economic systems and in turn, influence community response, activation, and social support, and ultimately community outcomes including social behaviors, community health, and quality of life (Patrick and Wickizer, 1995)
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McPLAN is part of this initiative. The process involved local health agencies and other healthrelated community organizations that promote health or work in related areas that contribute to health (e.g., education, jobs, hous
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In developing and implementing McPLAN, the McHenry County Department of Health has applied its experience over the past nine years in performance-based budgeting and community health needs assessment. These processes have been empowering for staff as well as community stakeholders.
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. The project coordinates a cross section of community services, including law enforcement, hospital emergency rooms, and community agencies.
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The state is making available to the CHNAs data on community characteristics and health status that can be used in assessing health needs and setting priorities. Experiences of the North Shore Community Health Network Area (NSCHNA)
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Other CHNAs in the state have chosen to focus on issues such as immunization and a reduction in sexually transmitted diseases among 15- to 19-year olds. Arizona Partnership for Infant Immunization10 The goal of the Arizona Partnership for Infant Immunization is to improve the preschool immunization rate in Arizona by influencing provider behavior.
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Calhoun County Health Improvement Program12 The Calhoun County Health Improvement Program (CCHIP) is a community-based program that began in 1993.
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They specifically addressed identifying stakeholders, selecting health priorities and indicators, using indicators for accountability, gaining community support for performance monitoring, and implementing a performance monitoring system. Identification of Stakeholders As described by the panelists, identification of stakeholders proceeds in one of two ways, depending on whether the stakeholders are involved in defining or responding to the problem.
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Selecting Health Issues and Performance Indicators Epidemiologic data are often used to guide the selection of performance indicators, but community interest may argue for focusing attention on specific issues or indicators, even in the absence of supporting epidemiologic data. It was noted that in some cases, a "triggering event" may focus attention on a particular health issue.
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Some participants emphasized the importance of including private-sector stakeholders early in the planning stages in order to frame questions in a manner compatible with existing data bases. Distinguishing performance indicators from overall program evaluation was raised as an important distinction.
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Tension between health problems articulated by the community and health problems identified by data analysis can potentially undermine community support for performance monitoring and health improvement activities. Participants suggested that the specific approach to selecting health issues should involve a larger community collaborative.
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Emphasis is shifting from individual health to population-based health; from tertiary to primary care; from preventive care to health promotion. Tension between controlling costs and improving health complicates change in all dimensions.
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For maximum impact, health interventions are chosen with attention to the individual's stage of readiness. The Health Belief Model views behavioral change as the result of "triggers" (Rosenstock et al., 1988)
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. A study of change in health care and health policy identifies processes of change used by managers, as well as expected and actual health outcomes (Casebeer, 1996)
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COMMENTARY14 The workshop discussions served as the basis for a commentary on community-based performance monitoring and issues to which the committee should give further attention. It was noted that the day's discussions focused broadly on community health improvement and community activation, rather than focusing more narrowly on performance indicators.
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Global health status indicators often have little practical use for guiding health improvement strategies. More useful are indicators that incorporate a "theory of improvement" -- that is, they suggest a clear means of moving from measurement to action.
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Such a model should • help communities clarify accountability and consider ways in which to include the private and public sectors as accountable entities; • identify performance indicators in the model of health improvement; indicators should not be expected to generate models of community improvement; • illustrate its concepts with the selection of a limited number of "performance areas" that are characterized by (a) evidence that services affect health status, (b)
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It was suggested that well-constructed coalitions of stakeholders can "keep the process honest." Ensuring meaningful consumer participation is another challenge shared by the programs, and is a topic that requires more attention. Panelists were sensitive to the need to listen both to stakeholders who are active participants and to those who are not before reaching conclusions about intervention strategies or performance indicators.
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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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In Health Promotion at the Community Level.
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448 IMPROVING HEALTH IN THE COMMUNITY Werner, E.E.
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Tony Traino, North Shore Community Health Network (Massachusetts) Laurie Carmody, Arizona Partnership for Infant Immunization Bonnie Rencher, Calhoun County (Michigan)
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FIELDING, Professor of Health Services and Pediatrics, University of California at Los Angeles, Los Angeles, California DENNIS J KELSO, Director, Health Care and Community Services Project, Escondido, California BONNIE RENCHER, Community Outreach Coordinator, Calhoun County Health Improvement Program, Battle Creek, Michigan TONY TRAINO, Associate Director, Home Care Operations, Visiting Nurse Association of Greater Salem, Salem, Massachusetts EDWARD H
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CATHY MERCIL, National Committee for Quality Assurance, Washington, D.C. MICHAEL MILLMAN, Health Resources and Services Administration, Rockville, Maryland NANCY RAWDING, National Association of County and City Health Officials, Washington, D.C.
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