Improving Health in the Community: A Role for Performance Monitoring

Our health is the final common expression of many factors. As a consequence, improving the health of individuals and communities requires our best understanding of what determines health and sickness and what medical, psychological, and societal forces must be harnessed to produce desired improvements in well-being. It is clear that improving our health ultimately requires a vision that is comprehensive and dynamic, yet realistic and feasible.

In 1994, the prestigious Institute of Medicine was commissioned by the U.S. Department of Health and Human Services and the Robert Wood Johnson Foundation to study how performance monitoring of a variety of health-modifying factors could be used to improve the health of communities. But what is “performance monitoring”? What would or could be monitored? And how can something so abstract translate into improved health, safety, and quality of life?

For those new to these concepts, performance monitoring involves the selection of specific demographic or health factors that can be measured and that relate meaningfully to whatever health outcome is sought. For this text on the health of communities, the factors range from characteristics of a community (such as age, race, poverty, unemployment, death rates, child abuse, smoking, money spent on health care, health status) to very specific conditions of concern to a particular community (such as vaccine-preventable diseases, depression, violence, breast cancer, and cervical cancer). Performance measurement is based on the assumption that we can define what is important to our health, measure it, report it, compare it, and use these data to improve our health.

This text details the work of an exceptional group of experts. Their thinking about how to measure population health and health improvement is detailed in the first half of the book. A great deal of the remainder of the text is given over to an appendix of “indicator sets.” What are “indicator sets”? For those new to this concept, an indicator set is a meaningful set of measures of the health and well-being of a community and its ability to improve its health status. The authors provide indicator sets in nine areas: 1) breast and cervical cancer, 2) depression, 3) elder health, 4) environmental and occupational lead exposure, 5) health care resource utilization (read expenditures), 6) infant health, 7) tobacco use, 8) vaccine-preventable diseases, and 9) violence.

Each indicator set contains a variety of highly specific performance measures by which consumers, government, purchasers, providers, accreditors, and others can profile a community for the disorder or problem in question as well as assess the community’s ability to act on improving the health status of its population. For example, depression. Sample performance measures of depression that would inform and guide health improvement for this disorder might include rates of adult depression and suicide, rates of high school student suicide attempts, numbers of uninsured, access to care, and whether depression treatment is clinically appropriate. For violence, sample measures might include rates of firearm deaths, rates of community assault/rape/attempted rape, whether gun control laws are in place, and the percentage of youths carrying weapons to school.

By constructing two types of performance measures (i.e., a community profile and indicators for a specific disorder or problem), it is possible to understand the health of a community and where it might focus and how it might set priorities on health improvement strategies. Heady stuff? Yet this is how we are already attacking tobacco use, street crime, and (to some extent) domestic violence. What is remarkable about this text is how clearly it conceptually structures these critical endeavors and then offers methods and case examples. There is even a wonderfully insightful section on how to manage change (a.k.a. resistance in psychiatric circles). The authors have succeeded in keeping their concepts realistic and feasible, while mapping out a plan for the future.

APA has undertaken a critical and related initiative for defining, measuring, and reporting the quality of care provided to patients with psychiatric disorders (1). Other important examples exist (2). Performance measurement is becoming a vital and inescapable element in the delivery of health care services.

Like any new field, problems abound. If we are so carefully to inspect a population, how do we protect its privacy and ensure confidentiality? How can such important data be collected in a manner that itself does not bankrupt the care system? Who actually has computerized information systems capable of this work? How can purveyors of individual health (the medical care establishment) better bridge their work with that of the keepers of the public health? How can so varied an assemblage of actors coordinate and cooperate to get something done?

America is worried about its health. Almost 15% of the gross national product is devoted to health care, more than 40 million people are uninsured and many more are underinsured, quality is demonstrably uneven throughout the country (3), and proprietary managed care organizations have been recognized finally as not the solution to cost and quality. We need a new paradigm. Quality may be that paradigm and performance measurement and quality improvement its arms and legs. Improving Health in the Community: A Role for Performance Monitoring is another important contribution from the Institute of Medicine. This text advances our critical thinking as we search for new ways to continuously improve the health of our patients and communities.