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Improving Health in the Community: A Role for
Performance Monitoring
Jane S. Durch, Linda A. Bailey, and Michael A. Stoto,
Editors; Committee on Using Performance Monitoring to
Improve Community Health, Institute of Medicine
ISBN: 0-309-52081-9, 496 pages, 6 x 9, (1997)
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Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
PREFACE i
Improving Health
in the Community
A Role for
Performance Monitoring
Committee on Using Performance Monitoring
to Improve Community Health
Jane S. Durch, Linda A. Bailey, and Michael A. Stoto, Editors
Division of Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1997
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of
the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist
distinguished members of the appropriate professions in the examination of policy matters
pertaining to the health of the public. In this, the Institute acts under the Academy’s 1863
congressional charter responsibility to be an adviser to the federal government and its own
initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine
is president of the Institute of Medicine.
Funding for this project was provided by the Office of the Assistant Secretary for Health, U.S.
Department of Health and Human Services (contract no. 282-94-0032); The Robert Wood
Johnson Foundation (grant no. 024336); and the Kellogg Endowment Fund of the National
Academy of Sciences and the Institute of Medicine. The views presented in this report are
those of the Committee on Using Performance Monitoring to Improve Community Health and
are not necessarily those of the funding organizations.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Using Performance
Monitoring to Improve Community Health.
Improving health in the community : a role for performance
monitoring / Committee on Using Performance Monitoring to Improve
Community Health ; Jane S. Durch, Linda A. Bailey, and Michael A.
Stoto, editors.
p. cm
Includes bibliographical references and index.
ISBN 0-309-05534-2
1. Community health services—United States—Evaluation.
2. Health status indicators—United States. 3. Health promotion—
United States. I. Durch, Jane. II. Bailey, Linda A. III. Stoto,
Michael A. IV. Title.
[DNLM: 1. Community Health Services—standards—United States.
2. Quality Assurance, Health Care—organization & administration—
United States. 3. Community Health Planning—methods—United
States. 4. Health Status Indicators—United States. WA 546 AA1
I59i 1997]
RA445.I575 1997
362.1¢2—dc21
DNLM/DLC
for Library of COngress 97-6336
CIP
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Copyright 1997 by the National Academy of Sciences. All rights reserved.
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Institute of Medicine is based on a relief carving from ancient Greece, now held by the
Staatlichemuseen in Berlin.
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
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COMMITTEE ON USING PERFORMANCE MONITORING
TO IMPROVE COMMUNITY HEALTH
BOBBIE A. BERKOWITZ* (Co-Chair), Deputy Secretary,
Washington State Department of Health, Olympia,
Washington
THOMAS S. INUI† (Co-Chair), Professor and Chair, Department of
Ambulatory Care and Prevention, Harvard Medical School
and Harvard Pilgrim Health Care, Boston, Massachusetts
ALAN W. CROSS (Vice Chair), Professor of Social Medicine and
Pediatrics and Director, Center for Health Promotion and
Disease Prevention, University of North Carolina, Chapel Hill,
North Carolina
LARRY W. CHAMBERS, Epidemiology Consultant, Hamilton-
Wentworth Regional Public Health Department, and
Professor, Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Ontario,
Canada
THOMAS W. CHAPMAN,‡ Chief Executive Officer, George
Washington University Hospital, and Senior Vice President
for Network Development, George Washington University
Medical Center, Washington, D.C.
ELLIOTT S. FISHER, Co-Director, Veterans Affairs Outcomes
Group, Veterans Affairs Medical Center, White River
Junction, Vermont, and Associate Professor of Medicine and
Community and Family Medicine, Dartmouth Medical
School, Hanover, New Hampshire
JAMES L. GALE, Professor, Department of Epidemiology, School
of Public Health and Community Medicine, and Director,
Northwest Center for Public Health Practice, University of
Washington, Seattle; Health Officer, Kittitas County,
Washington
KRISTINE GEBBIE† (Liaison, Board on Health Promotion and
Disease Prevention), Assistant Professor of Nursing, Columbia
University School of Nursing, New York, New York
FERNANDO A. GUERRA, Director of Health, San Antonio
Metropolitan Health District, San Antonio, Texas
*As of July 1, 1996, Deputy Director, Turning Point Program, University of
Washington School of Public Health and Community Medicine, Seattle.
† Member, Institute of Medicine.
‡ Served through December 1995.
iii
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
GARLAND H. LAND, Director, Center for Health Information
Management and Epidemiology, Missouri Department of
Health, Jefferson City, Missouri
SHEILA LEATHERMAN, Executive Vice President, United
HealthCare Corporation, Minneapolis, Minnesota
JOHN R. LUMPKIN, Director, Illinois Department of Public
Health, Springfield, Illinois
WILLIAM J. MAYER, President and General Manager, Functional
Foods Division, Kellogg Company, Battle Creek, Michigan
ANA MARIA OSORIO, Chief, Occupational Health Branch,
California Department of Health Services, Berkeley,
California
SHOSHANNA SOFAER, Associate Professor and Associate Chair
for Research, Department of Health Care Sciences, George
Washington University Medical Center, Washington, D.C.
DEBORAH KLEIN WALKER, Assistant Commissioner, Bureau of
Family and Community Health, Massachusetts Department
of Public Health, Boston, Massachusetts
JOHN E. WARE, Jr.,‡ Senior Scientist, The Health Institute, New
England Medical Center, Boston, Massachusetts
RICHARD A. WRIGHT, Director, Community Health Services,
Denver Department of Health and Hospitals, Denver,
Colorado
Study Staff
Linda A. Bailey, Senior Program Officer (Co-Study Director)
Jane S. Durch, Program Officer (Co-Study Director)
Stephanie Y. Smith, Project Assistant
Michael A. Stoto, Director, Division of Health Promotion and
Disease Prevention
Marissa W. Fuller, Research Associate
Sarah H. Reich, Project Assistant
Susan Thaul, Senior Program Officer
‡ Served through December 1995.
iv
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
Preface
A
n interest in understanding how health care and
public health activities might be coordinated and directed toward
improving the health of entire communities was the basis for this
study by the Institute of Medicine (IOM) Committee on Using Per-
formance Monitoring to Improve Community Health, which we
jointly chaired.
The IOM was asked by the U.S. Department of Health and
Human Services and The Robert Wood Johnson Foundation to
undertake a two-year study to examine the use of performance
monitoring and develop sets of indicators that communities could
use to promote the achievement of public health goals. The study
was originally approved in mid-1994 when passage of federal
health care reform legislation was anticipated. Part of the task
outlined at that time was to identify public health indicators that
could be measured through the national information network that
was envisioned in the proposed Health Security Act.
By the committee’s first meeting, comprehensive federal legis-
lation was no longer expected and attention had shifted to oppor-
tunities for collaborative public–private activities at state and lo-
cal levels. This change in the national policy environment resulted
in further discussion with the study’s sponsors to reframe the
committee’s task. After the committee’s second meeting, a “vision
statement” and work plan reflecting this modified context were
developed in consultation with the sponsors. The vision state-
v
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
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vi PREFACE
ment appears in Appendix C of this report along with the sum-
mary of the committee’s first workshop.
The revised task called for the committee to examine how a
performance monitoring system could be used 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 pub-
lic and private sector entities. The committee was also asked to
develop prototypical sets of indicators for specific public health
concerns that communities could use to monitor the performance
of public health agencies, personal health care organizations, and
other entities with a stake in community health.
The committee appointed to conduct the study brought to-
gether expertise in state and local health departments, epidemiol-
ogy, public health indicators, health data, environmental health,
adult and pediatric clinical medicine, managed care, community
health and consumer interests, quality assessment, health ser-
vices research, and employer concerns. The group met six times
between February 1995 and April 1996. Workshops held in con-
junction with our meetings in May and December 1995 gave us
the opportunity to hear about a variety of community experiences
and to learn more about work on performance monitoring being
done by academic researchers and public and private organiza-
tions. Summaries of these workshops appear as Appendixes C
and D of this report and also are posted on the World Wide Web
(http://www.nap.edu/readingroom/).
The committee reviewed critical issues in using performance
monitoring and the role it can play in community-based health
improvement efforts. Our work pointed to the need for a broad
view of the determinants of health and of the stakeholders that
share responsibility for maintaining and enhancing health in a
community. In this report, we propose an iterative and evolving
community process for health improvement efforts in which per-
formance monitoring is a critical tool for establishing meaningful
stakeholder accountability. We also propose a set of indicators as
the basis of a community profile that can provide background
information needed to understand a community’s health issues
and can help communities identify specific issues that they might
want to address. In addition, the committee developed prototypes
of sets of performance indicators for some of those specific health
issues (see Appendix A). The committee’s work in developing these
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
PREFACE vii
indicator sets illustrates how communities might apply the ap-
proach described in our report.
In the course of the committee’s work a shared awareness
evolved of the ways in which the public health and health care
systems contribute to a community’s well-being. Beyond the usual
tasks of IOM committees—always complicated by subject com-
plexity, relevance of multiple legitimate perspectives, and the need
to forge multidisciplinary consensus—the committee’s work re-
quired bridging what Kerr White has called the “schism” between
the public health and personal care systems.1 Furthermore, we
also needed to bring together three conceptual domains that have
arisen separately—determinants of health, continuous improve-
ment, and social activism. Finally, if these circumstances were
not sufficiently daunting, a conceptual process that we entered
into required major envisioning of systems not yet established,
partnerships not yet forged, and the way in which individuals in
organizations from different social sectors might choose to work
together both for the common good and out of enlightened self-
interest.
Our committee’s principal “product” was a community health
improvement process (CHIP), a method by which, on a commu-
nity-wide basis, the health of the population might be improved.
However complex this process of assessment, analysis, strategy
formation, evaluation, and reassessment might be, we heard in
our workshops individual presentations on programs and activi-
ties that seemed to us to represent the major features of our
conceptual scheme at work in communities today. These current
activities were never as holistically conceived, adequately re-
sourced, thoroughly documented, and effective as our idealized
vision of a possible future. They nevertheless represented steps
toward a system of community-level effort that we believe will be
necessary if the health of our community populations is ever to be
truly maximized within available resources. Seeing and hearing
about actual community cases in the present day encouraged us
to think that the larger, more systemic achievement of a commu-
nity health improvement process might yet be within our grasp.
For too long, the personal health care and public health sys-
tems have shouldered their respective roles and responsibilities
for curing and preventing separately from each other, and often
1K.L. White. 1991. Healing the Schism: Epidemiology, Medicine, and the Public’s
Health. New York: Springer-Verlag.
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
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viii PREFACE
from the rest of the community as well. However, working alone
and independently, our formal health systems cannot substan-
tially improve population health at the level of fundamental deter-
minants. The burden on these systems and the lost opportunities
in our society from this fragmentation, segmentation, and isola-
tion are evident in the resources consumed in repeatedly respond-
ing to the health consequences of persistent problems that can be
traced to a variety of factors.
Instead, we need to invest in a process that mobilizes exper-
tise and strategic action from a variety of community, state, and
organizational entities if we are to substantially improve commu-
nity and population health. The committee’s experience over the
course of this study suggests that developing a strategy for perfor-
mance monitoring for health improvement at a community level
constitutes a lens through which all potential contributors to com-
munity health become visible, their legitimate domain for action
can be examined, and a virtually unlimited array of specifiable
indicators of performance can be considered. In a complex, cross-
sectorial collaborative strategy, indicators for successful contribu-
tions to the overall strategy can help assure all parties that the
effort each is making is having its intended effects. The challenge
to communities will be to choose such measures wisely, using a
method of choice-making that the committee hopes we have made
explicit in this report.
No complete working model of the committee’s vision will
emerge quickly or easily. In particular, the emergence of partner-
ships to improve the health of communities, when that process
entails the assumption of real accountability for measured perfor-
mance, is likely to proceed slowly at first. However, the committee
looks forward to seeing its proposed CHIP translated into practical
applications, tested in a variety of community contexts, and im-
proved. This will require a blend of imagination and creativity
that will challenge, and we hope energize, all involved.
In closing, we note that this committee’s work complements
that of several other current or recently completed studies at the
IOM and the National Research Council. A particularly closely
related study, being conducted by the National Research Council’s
Panel on Performance Measures and Data for Public Health Per-
formance Partnership Grants, is examining technical issues in-
volved in establishing state-level performance measures for fed-
eral grants in eight substantive areas. The panel’s first report,
Assessment of Performance Measures in Public Health, which was
released for comment in draft form in September 1996, is sched-
Copyright © National Academy of Sciences. All rights reserved.
Improving Health in the Community: A Role for Performance Monitoring
http://www.nap.edu/catalog/5298.html
PREFACE ix
uled for completion in early 1997. A second report will address
data and data system development needs.
Three related IOM reports were released in November 1996.
Healthy Communities: New Partnerships for the Future of Public
Health, from the Committee on Public Health, examines the evolv-
ing role of public health agencies, particularly in relation to com-
munity-focused activities and the growing prominence of man-
aged care. The Hidden Epidemic: Confronting Sexually Transmitted
Diseases, from the Committee on Prevention and Control of Sexu-
ally Transmitted Diseases, focuses on a specific health issue for
which community-level efforts are recommended along with
broader state and national strategies. Managing Managed Care:
Quality Improvement in Behavioral Health, the report of the Com-
mittee on Quality Assurance and Accreditation Guidelines for
Managed Behavioral Health Care, presents a framework for ac-
creditation standards and quality improvements for managed be-
havioral health care and for developing, using, and evaluating
performance indicators. We also note that our study is one of
several that are part of the IOM Special Initiative on Health Care
Quality, a three-year effort with goals that include evaluating and
promoting appropriate use of tools for quality assessment and
improvement.
We want to express our appreciation to the many people—
listed by name in the Acknowledgments—who aided the commit-
tee in its work. As co-chairs of this difficult but rewarding study,
we also want to commend the members of the committee for their
thoughtful and insightful approach to the task put before them.
Finally, on behalf of the entire committee, we want to thank the
members of the IOM staff whose efforts successfully translated
the committee’s work into this report. Susan Thaul and Sarah
Reich guided us through the initial meetings and workshop. Linda
Bailey, Jane Durch, and Stephanie Smith, who joined the study
staff in the midst of this process, saw us through additional meet-
ings and another workshop as well as writing the report. Michael
Stoto has been a valued contributor throughout the project.
Bobbie A. Berkowitz
Thomas S. Inui
Co-Chairs
Copyright © National Academy of Sciences. All rights reserved.
