Section 6. The Institute of Medicine's Community Health Improvement Process (CHIP)

Learn how to utilize a participatory framework for promoting community health using assessment, prioritization, and monitoring.

 

The Institute of Medicine (IOM) is an independent, non-profit research and public information organization that’s a component of the National Academy of Sciences. IOM would like you to think about something. Suppose you mount a community effort to deal with an important local issue – let’s say domestic violence. You put together a group to spearhead your effort, study the issue in the community, and come up with a plan.

You realize that domestic violence has many dimensions. It’s not just the result of someone losing his temper once in a while, but rather part of a recurring pattern. In addition, it has ties to substance use, unemployment and other economic circumstances, and a social climate that makes it acceptable, at least up to a point.

So your group sets out to address all the aspects of the problem. Police may have to be trained, and they and the courts may have to change their attitudes toward domestic violence. Safe havens have to be established for family members who’ve been violently abused or attacked. Families – including the abusers, the abused, and witnesses to the abuse – need counseling. Substance use has to be addressed and treated. In addition, attention has to be paid to job training, not to mention the overall economic situation of the community. Finally, there has to be a public education campaign to convince the community that domestic violence is not a normal part of a relationship.

Each element of your plan requires an action, and each action requires someone to carry it out. Furthermore, you’ll need someone or some group in the coalition to coordinate and oversee the whole process. A complex plan won’t work unless everyone does what is expected.  That’s a major concern of the IOM. It believes that accountability is often overlooked in community health and development planning, and is a crucial ingredient in creating a healthy community.

This section will describe CHIP (Community Health Improvement Process), the IOM model, which is similar to others in this chapter in many ways – it’s participatory; takes a community perspective; embodies a broad view of health; calls for community assessment, strategic planning, and evaluation in intervention, etc. – but features an accountability component. IOM believes that performance monitoring – starting off with a clear statement of everyone’s responsibilities, and then checking regularly, using quantitative measures of performance, to make sure that those responsibilities have been carried out and have been effective – can make the difference between success and failure in a drive to build a healthy community.

What is a CHIP?

CHIP is a framework for a process for building community health. As explained above, it has a performance monitoring element built in. It is specific about process – the way you go about creating a community health effort – but not about content – the issues you might tackle or the methods you might use to tackle them. Content is left up to individual communities.

You could read the words “Community Health Improvement” in two ways: (1) the improvement of the overall physical health of the individuals who make up a community; or (2) the improvement of the health of the community itself. IOM largely concerns itself with the first possibility, but we’ll concentrate on the second, in keeping with the fact that the Community Tool Box is concerned with all aspects of community functioning. Striving for a healthy community, instead of community health, doesn’t change the CHIP framework at all, but gives us the leeway to address various aspects of community life, rather than health alone.

The diagram below describes the CHIP model using graphics. The text that follows explains the components of the model and how they relate to one another.

From J.S. Durch, L.A. Bailey, and M.A. Stoto, eds. Improving Health in the Community, Washington, DC: National Academy Press, 1997.

As the model diagram shows, a CHIP has two cycles – cycles because each is seen as a sequence that can and should be repeated over the course of time. A cycle can be initiated in any of its phases, although the implication of the diagram seems to be that there is a “most logical” sequence that most communities will use, and that we’ll use here.

The problem identification and prioritization cycle

In this cycle, you start with an area of concern – health in the original IOM conception, but as we’ve discussed, it could as easily be the overall quality of community life – assess the situation, identify areas that the community needs to work on, and decide where you’ll put your energies.

• Form a community coalition to address community health/quality of life. There has to be some coordinating body for such an effort. A coalition satisfies the demands of the IOM model for inclusiveness and broad participation. It implies a relationship of equals working toward a common goal, and makes it easier to bring people and organizations together than would a more hierarchical structure.
• Prepare and analyze community profiles. This is the process of examining the various factors that could influence community well-being. Looking at the results of your analysis should highlight the problem areas that most need to be addressed. IOM suggests five areas to examine:
  • Sociodemographics. Age, geographic distribution, race/ethnicity, income, employment, housing, etc.
  • Status of the issue. The frequency and seriousness of issues in the community, whom they affect, related issues and their effects and frequency. Frequency and seriousness are both important. A very large number of cases of small, easily cured skin cancers may be a matter of concern, for instance, but not as much concern as a somewhat smaller number of cases of lung cancer, many or most of which prove fatal.
  • Risk and protective factors. The factors already existing in the community that make people more or less likely to be affected by particular issues. The absence of laws prohibiting children and teens from purchasing cigarettes may be a risk factor for that lung cancer epidemic; enforced no-smoking laws in restaurants and public buildings may be a protective factor.
  • Resource consumption on issues. The community resources (services, funding, etc.) already devoted to particular issues.
  • How people view the issues with respect to themselves. To what extent do they report being affected by them? If people don’t see an issue as a problem that affects them in some way, or as something important, it’s difficult to involve the community in action on that issue.
  • This profile will help you decide what issues to work on, and will be useful to the community in examining itself in many ways, and in continuing the work of the CHIP after the initial effort has been completed.
• Identify the critical issues (the problem). What are the most critical needs in the community? What issues motivate – or could motivate – citizens to work on them?  What does the community have the resources to do? On what issues can you actually make a difference? These are the questions to ask in deciding what issues you’ll address.

The “problem” here is assumed to be an aspect of a larger concern (specifically health, in the original IOM conception). It may be an actual specific problem – teen pregnancy, homelessness, tuberculosis, violence, the school dropout rate – but could also be a community asset that needs to be developed – youth leadership, an empty historic building – or the creation of something new that contributes to the health and well-being of the community – a community arts center, a well-baby program.

• Once you’ve identified the issues you plan to work on, you move on to the next cycle, that of analysis and implementation. The diagram above describes the second cycle of the process for one issue. If the CHIP has identified and means to address several issues – domestic violence, gang activity, and child sexual assault, for example – then it will go through an analysis and implementation cycle for each of them.

The analysis and implementation cycle.

Here, you work out both a long-term strategy and an action plan to effectively resolve the issue at hand, assign responsibility for each element of the plan, put it into effect, and then monitor your results to determine whether everything is working properly, and whether all partners are fulfilling their responsibilities.

• Analyze the issue. Using the information it has gathered, its knowledge of the community, reports of best practices, and the available research, the coalition analyzes the issue. IOM’s model, like PRECEDE/PROCEED. Healthy Communities, and others, emphasizes that both individual and community health are greatly influenced by a combination of social, physical, and genetic environmental factors, as well as by economic and political conditions. Thus, the natural environment, the gap between the top and bottom of the community economic ladder, the racial or ethnic groups in the community, the employment situation, and the attitudes of those in power toward the role of government may all have a profound effect on a particular issue or on the general quality of community life.
• The goal here is to understand the particular factors that cause or lead to the issue you’re concerned with, how they play out in the community, and how they can best be approached. You should be careful to consider all possible factors, not just those that are obviously related to the issue.
• Inventory your resources. What do the coalition and the community have available to address issues?
  • Local assets. Organizations and institutions, local foundations and other funders, expertise, current services, etc
  • Protective factors within the community. Family, social, and faith networks; community norms and values, physical environment, community activities, etc.
  • Human resources. “Natural helpers,” academic researchers, links to particular groups in the community, people with skills in relevant areas.
  • Resources from outside the community. Nation- and statewide public and private funding sources, for instance, or sources of technical assistance.
• Develop a strategy. Understanding the issue and having a clear sense of available resources will help you to come up not only with a short-term plan for addressing the specific issue you’re currently focusing on, but also with a strategy for promoting and maintaining community well-being over the long term. Your strategy should be geared to your community, and should be arrived at through an inclusive, participatory process.
• Identify accountability. Your coalition or partnership – with the input and collaboration of those who will be carrying out the plan (if all has gone well, they’ll be involved already) – determines who will be responsible for which elements of the plan.  You should identify who will oversee each part of the process, who is responsible for carrying out the actual work of a particular intervention or piece of an intervention, who will evaluate and provide feedback, etc. There are some important considerations as you agree on accountability:
  • It should be realistic. Before individuals or groups take on responsibility for a part of the process, you should make sure that they have the resources, capacity, and support to accomplish what they’re attempting. To assign accountability to someone who can’t succeed is both unfair and counterproductive.
  • It should be voluntary. If accountability is to mean anything – and if it is to lead to results – it must be taken on willingly. Individuals or groups that accept accountability for an element of the strategy are also agreeing to think carefully about what they do, to be willing to change course if their efforts aren’t working or if community needs change, to accept constructive criticism without defensiveness, and to see themselves as integral parts of a larger effort. If they accept accountability under pressure, or disagree with the accountability process, they’re unlikely to agree to any of that, and their supposed accountability won’t make much difference.
  • It should involve clear and observable responsibilities. Both the accountable individuals/organizations and the coalition should understand exactly what they’re agreeing to, and how they’ll determine whether and how responsibilities have been met. Clarity makes performance itself and its monitoring easier, confirms that you’re operating with a coherent and understandable plan, and – because everyone knows exactly what he’s supposed to do – increases the chances of success.

No matter how carefully you plan, you can’t anticipate everything that might or will happen, and you should expect surprises. If you plan carefully, however, and try to be as clear as possible, there will be fewer of them, and they’ll breed less bad feeling among those who find themselves surprised. As long as everyone agrees at the beginning that the responsibilities they’re taking on are reasonable and achievable, unexpected events and circumstances can be weathered.

• Develop a set of performance indicators in order to be able to monitor the process, outcomes, and performance. Accountability should be measurable, and should be based on what needs to be accomplished. Its point is not to single out or punish those who don’t reach their intended goals, but rather to:
  • Help those who are having difficulty improve their performance. This might be through better support, redefining goals, changing methods or techniques, switching staff around, focusing on a different group of participants, changing to a more realistic timeline – whatever it takes to make sure that what they do has the desired effect.
  • Identify problems in the system. It may be that performance is ineffective because the reasons for it are simply invalid, or because you conceived of the issue in the wrong way to begin with. Performance problems can often shed light, not on the failures of those responsible, but on the inadequacy of the system within which they are working.
  • Help everyone learn and improve both action plans and the overall strategy.

IOM specifically suggests that indicators should be quantitative – i.e. tied to numbers, such as the number of people served, or the average time participants spend in a program – but there are other ways to assure that accountability is measurable. Qualitative measures such as observation, participants’ own reports, and community impressions may also provide accurate and important information relating to accountability. Numbers don’t always tell the whole story.

The point of accountability here is not to make it easier to assign blame if something doesn’t get done or go as planned. Rather, it is to make it possible to improve your strategy and actions so that they become more effective. If there’s a failure in the system, clear accountability enables you to figure out where it happened and why. Then you can take action to correct it, whether that’s providing better support to whoever’s responsible, or rethinking your strategy entirely.

• Implement your strategy. Do whatever you’ve decided is necessary – intervention, program, community education initiative, etc.
• Monitor the process and outcomes. As with other models (PRECEDE/PROCEED, for example), the concern here is both with process and outcomes.
  • Process: Did you do what you set out to do (e.g., deliver a specific service to a specific number of people in a specified time frame)? If not, why not?
  • Outcomes: What effect did your actions have? Was it the desired effect, or at least positive? If not, why not?

If the process broke down, or the outcomes weren’t satisfactory, you should be able to analyze the situation, and pinpoint what went wrong and how by using the performance indicators that you developed in phase 5. Then you can choose from a number of possible courses of action to correct mistakes or misconceptions, bolster the performance of an organization that wasn’t able to accomplish what it expected to, etc. Among the possibilities:

• Change your strategy or action plan.
• Shift responsibility elsewhere.
• Provide more support and/or resources to those accountable.
• Eliminate a particular action or element of strategy.
• Start the cycle again, with another issue or group of issues. What you’ve done so far may have resolved some issues, or may have only made clear how complex they are. Whatever the result, you’re not done: the ultimate aim here is long-term, fundamental change that improves life in the community. Whether you’re moving up to a larger concern, or merely addressing a different issue, there will always be a next step in the process.

Why use a CHIP?

Why would you employ the CHIP model as opposed to another? There are a number of reasons why this model might be a good one for many communities.

•  It takes a community perspective. CHIP asks you to consider the whole community when you address an issue. That broad perspective is most likely to encompass the real causes – and best resolutions – of issues that need to be addressed.
• It’s inclusive and participatory. The CHIP model not only considers but involves the whole community in generating strategy and carrying it out. That means that a wide range of opinions, viewpoints, and ideas go into a strategy, and that the community owns the eventual effort. Community ownership in turn leads to enthusiastic community support, and a willingness to work for the effort and see it through.
• It demands a comprehensive view of health. Again, like many of the other models in this chapter, CHIP sees health as not only the absence of disease or a chronic condition. Community health is health in all senses – social, economic, political, ecological, etc. (The Evans and Stoddart field model illustrated earlier provides an example of this comprehensive view.) This view allows you to consider all community issues when addressing community health, making it far more likely that they will be resolved.
• It sees equity as a key. Equity – the condition of everyone in a community getting what she needs for a decent quality of life – has been shown to be a prime factor in both individual and community health by the World Health Organization. The fostering of equity is crucial to the creation of a healthy community, and to the establishment of social justice in a community or a society.
•  It’s flexible. The model leaves the community to determine the structure and content of its strategic and action plans, based on its own analysis and knowledge of its own needs.
• It builds in accountability. As discussed above, that makes it possible to structure an effort clearly, and to identify gaps in it as they appear.
• It builds in performance monitoring. Not only does performance monitoring make accountability a reality, but it allows pinpoint course correction as it identifies problem areas in strategy or in the implementation of an effort.
• It can incorporate or fit in with other models. CHIP can be used as the framework for a healthy community effort, for instance. Its flexibility in form and content makes it adaptable to a wide range of circumstances.
• It sees the process as ongoing and long-term. Real change is not a one-shot affair. It takes place over time, and as a result of constant, steady effort. CHIP recognizes that, and its cyclical model is one that is meant to be used over the long term.

Perhaps the model’s biggest drawback is that, while it advocates inclusiveness and participatory planning, it’s essentially top-down. It assumes that the initial planning and spearheading of the effort will be done by “experts” of some sort – public health officials, medical administrators, legislators, etc. Although others are invited to join, the group that does the inviting will have already formed, and will undoubtedly have its own ideas about how things should go. This is different from gathering a large number of participants from diverse backgrounds at the very beginning, and hashing out where to start and how to proceed.

Who should be part of a CHIP?

A CHIP should involve all stakeholders, i.e. those who are in any way affected by or involved in a community health or development effort. These include:

• Those who are directly affected by the issue at hand. They may, for example, be perpetrators or victims of violence, subject to a particular disease or physical condition, unemployed because of community economic circumstances, homeless, etc.
• Those whose lives or jobs will be affected by the CHIP effort. In addition to those at whom any intervention or program is directly aimed, this group includes anyone who is involved in carrying out the effort (health and human service staff, police, teachers, etc.), and anyone who is indirectly affected (landlords, property owners, public agencies, employers, etc.)
• Change agents. Those with the power and authority to create change: public officials, lawmakers, potential funders, and opinion leaders.
• Influential people. The business community, clergy, leaders of various groups, ordinary citizens who have the respect of the community.
• Community members at large. Since the process demands commitment by and accountability to the community, it makes sense to involve community members in it.

How do you implement a CHIP?

IOM guidelines

As we’ve discussed, the CHIP model, by design, offers no specific methods or techniques, so that a community can design a strategy that fits its needs. IOM does, however, recommend some basic guidelines for successfully implementing a CHIP.

The following is from J.S. Durch, L.A. Bailey, and M.A. Stoto, eds., Improving Health in the Community. Washington, DC: National Academy Press, 1997.

• Communities should base a health improvement process on a broad definition of health and a comprehensive conceptual model of how health is produced within the community.
• A CHIP should develop its own set of specific, quantitative [i.e., number-based] performance measures, linking accountable entities to the performance of specific activities expected to lead to the production of desired health outcomes in the community.
• A CHIP should seek a balance between strategic opportunities for long-term health improvement and goals that are achievable in the short term.
• Community coalitions guiding CHIPs should strive for strategic inclusiveness, incorporating individuals, groups, and organizations that have an interest in health outcomes, can take actions necessary to improve community health, or can contribute data and analytic capabilities necessary for performance monitoring.
• A CHIP should be centered in a community health coalition or similar entity.
• State and local public health agencies should assure that a community health improvement process is in place in all communities. These agencies should at a minimum participate in CHIP activities, and, in some communities, should provide its leadership and/or organizational home.
• In support of community-level health improvement processes, state health agencies, in cooperation and collaboration with local health departments, should assure the availability of community-level data needed for health profiles.
• States and the federal government, through health departments or other appropriate channels, should require that health plans, indemnity insurers, and other private entities report standard data on the characteristics and health status of their enrolled populations, on services provided, and on outcomes of those services, as necessary for performance monitoring in the community health improvement process.

The last four of these guidelines demonstrate the top-down nature of the IOM concept, and the last would seem to question the voluntary nature of accountability discussed earlier. If yours is a grass roots or community-generated effort, an inclusive coalition – either one that already exists, or one that forms to address community need – could provide collaborative leadership for a CHIP-type process. Data, both for community assessments and performance monitoring, can be gathered by participants from the Internet, organizational and community records, and other public documents, without the intervention of government agencies. In other words, a community-change process modeled on CHIP could easily be conducted collaboratively by the community, rather than under the oversight and leadership of a public health or other similar agency.

Steps those guidelines imply for implementing a CHIP

• Assemble a broad-based, inclusive, participatory coalition or coordinating council to guide the CHIP process, if one does not already exist.
• Do your research. Depending on the circumstances, that research will probably include examination of some or all of the following:
  • Census data, for demographic information.
  • Information on the issue(s) in the community. Some of this may be available from census data, some from public records of various sorts, some from the records of community-based and other non-profit organizations, some from interviews and surveys of the community, some from academic or other studies, etc. It should include the interaction of demographic information and the issue(s). (What’s the relationship of race, for instance, or gender to the frequency of the issue? Is it experienced more by the old than the young, or more by people in specific geographic areas? Is it evenly spread throughout the community?  Is it related to employment, economic status, education, genetics, living conditions, etc.?)
  • Community attitudes about the issue(s). You’ll learn about these from a community survey, from group or individual interviews, from focus groups, and/or from reliable community informants (people in the community whom you trust to give you an accurate reading of what you’re looking for).
  • The trends and realities of the issue(s). Are things getting better or worse? How do particular issues affect the lives of real people? How are the details of the issue likely to change in the foreseeable future (a move from cocaine toward heroin among hard drug users, for instance)? Most of this information will probably come from organizations that deal with the issue, and from people affected by it (substance use treatment programs and drug users, for example, in the case of drug use trends).
  • The theories and formal research results of those who have studied the issue(s) (commonly called “the literature” – the information that’s been published about the issues).
• Identify the issue(s) you’re going to work on, if you haven’t started with a specific issue in mind.
• Analyze the issue(s) carefully. That means looking at their possible root causes, the consequences – intended and unintended – of addressing and not addressing them, how they might be approached, etc. In order to conduct an accurate analysis, you’ll need to consider all the factors that impinge on health and other issues:
  • The social determinants of health. In broad terms, these fall into three categories: socio-economic equity, social connectedness, and sense of personal efficacy.
  • The nine factors – subsets of the broader social determinants listed above – that determine community health, as set out in the Ottawa Charter, the “Constitution” of the Healthy Communities movement: peace, shelter, food, education, income, a stable ecosystem, sustainable resources, social justice, and equity.
  • Factors that are fixed in one way or another: genetics, geography, demographic information, population patterns, etc.

An understanding of these factors and their interactions with one another and with the issue as it plays out in the community will help you carry out your analysis, and will also shed light on another important consideration: Are you in fact addressing the right issue(s) to create the changes you’re aiming for? It’s sometimes the case that an issue that seems self-contained is in fact a small part of a larger issue. That usually means that you won’t resolve your issue without tackling the larger one.

In doing an analysis of this sort, it’s often helpful to remember the story of the blind men and the elephant. Several blind men are introduced to an elephant and asked to describe it. The one who grasps the elephant’s trunk exclaims that the elephant is like snake. Another feels its leg and says that the elephant is like a tree. The man at the elephant’s tail says the animal is like a rope. And the one who feels its side says the elephant is like a wall. All of their analyses are correct as far as they go...but none of them go far enough. Make sure that you go beyond your first impression: don’t assume you’ve seen all there is to see about the issue.

• Take stock of potential resources, particularly those already available in the community. There are really three courses of action you should be taking here:
  • Start with a positive, proactive stance, and assume that the community already possesses many of the resources necessary to address its own issues and improve its quality of life. Then find and enlist the community assets – people, organizations and institutions, funding, etc. – that can contribute to your effort.
  • Decide whether more resources will be needed, and strategize about how – and from where – to get them.
  • Approach potential funders, and draw them into your CHIP process as participants, if you haven’t already.
• Develop a strategic plan and action plans to carry it out.The strategic plan should be devised by a group representing all sectors of the community, so that it will both respond to the realities of the community situation and be seen as belonging to the community.

There are really two plans needed:

• A long-term strategic plan to address systemic change in the community. Carrying out this plan will lead not only to the permanent resolution of your issue, but to lasting improvement in the well-being of the community. At the same time, it may cover a decade or more, which is a long time for people to wait for results.
• Shorter-term strategic goals that allow for some reasonably quick success. These are necessary not only to address immediate problems, but to keep people enthusiastic about the long term, and to benchmark your progress toward your eventual outcomes.

This is where the IOM guideline about striking a balance between long-term and short-term achievable goals becomes relevant.

• Agree on who will be accountable for which parts of the plan. As discussed above, accountability should be voluntary, involve realistic expectations, and be based on clearly defined and observable responsibilities.

Accountability doesn’t always mean that those accountable are responsible for doing what needs to be done, but rather that they are responsible for seeing that it gets done. Thus, an organization may take on accountability for something not in its area of expertise with the understanding that it will find and recruit the appropriate provider or practitioner to see that it gets done.

• Work out how accountability will be monitored. Here’s where you develop performance indicators to monitor the process and outcomes of your effort, and to see whether everyone did what they agreed to, and accomplished what they expected to. While IOM demands quantitative measures, it’s actually probably more informative and more accurate to use both quantitative and qualitative measures. Qualitative measures such as observation and participant self-reports often give information that the numbers either hide or fail to pick up entirely.
• Implement your strategy. By this point, you should have both a long-term strategy and an immediate action plan. It’s the action plan (or the first of your action plans, depending on what your overall strategy looks like) you’ll start out with, and it should include clear goals, a process, a clear statement of who’s accountable for what, and ways of measuring both performance and the success of your plan.
• Monitor both the process and the outcomes of your effort. Monitoring has two purposes: to make sure everyone’s doing what they’ve agreed to do and that it’s working (performance monitoring); and to see whether your overall plan is effective (outcome monitoring).

The point of performance monitoring, as mentioned earlier, is not to find someone to blame for not doing his job, but rather to find weak points in the system and strengthen them. If some organization, for instance, isn’t playing its part in the process, it may need more resources, technical assistance, or some other support. If the process is going as planned (everyone’s doing just what they’re supposed to do) and there are still no results, then someone might need to change methods, or address another facet of the issue.

Performance monitoring will tell you what you need to know about accountability and about whether the process is working. Outcome monitoring will tell you whether you need to adjust and refine – or rethink – your strategy and action plans. You may have misread the needs or attitudes of the community, banked on techniques that simply don’t work, or failed to respond to a change in the situation. Whatever the issue, if there’s no evidence of your hoped-for outcomes, it’s time to alter your approach.

Even if things are going well, there’s always room for improvement. Monitoring may also show you ways that you can tweak your effort to make things work better: improved communication and coordination, for instance, or increased concentration on a particular area might make success quicker and easier for everyone.

• Maintain your gains. No matter how successful an action plan is, it won’t amount to much if its successes aren’t maintained. The job isn’t over once an issue is resolved – it has to stay resolved, and that takes ongoing effort. Once you’ve accomplished something, you have to work indefinitely to keep it accomplished, even as you tackle the next task.

Maintenance is best accomplished through system change. The ideal solution is to put a new system in place, or change the community climate so a new behavior or condition is sustained automatically.  If that’s not possible – and it may not be, especially early in a long-term effort – then you simply have to keep paying attention to it, or you’ll lose what you’ve gained.

• Start the cycle again, with another issue. As we made clear at the beginning of this section, a CHIP isn’t a one-shot deal.  It’s meant to be an ongoing, long-term effort to change the community in fundamental ways. The cycles continue, tackling different issues, changing systems, and working to improve well-being and the quality of life for everyone in the community.

In Summary

The Institute of Medicine’s Community Health Improvement Process (CHIP) is a framework for promoting community health which may be used also as a model for creating healthy communities. It is similar to many of the other models in this chapter in that it takes a comprehensive, community-based view of health and starts with an inclusive, participatory, community-based coalition or coordinating group. In the first cycle of the (two-cycle) process, that group assesses and analyzes the community to identify the critical issues that impact the health of the community as a whole.

In the second cycle – a cycle duplicated for each issue that the CHIP addresses – the coordinating group analyzes the issue, inventories the resources available to address it, develops long-term and short-term strategy, identifies accountability for carrying out the strategic plan, develops measurable indicators for measuring both the performance of those accountable and the plan’s overall success, implements the strategy, monitors its process and outcomes, makes whatever adjustments and changes are necessary, and then repeats the cycle, with the same or another issue.

A CHIP has a number of advantages. It takes a community-based and comprehensive perspective on health, allowing it to consider any factor that is relevant as a contributor or barrier to the building of a healthy community. It’s inclusive and participatory, and sees equity as a key factor in community health, thus involving and paying attention to all the voices and interests in the community. It’s flexible, encouraging communities to create solutions that reflect the real needs and circumstances of individual communities.  It builds in accountability and monitors performance to assure that accountability is honored. It can incorporate or fit in with other models. And perhaps most important, it sees the process as ongoing and long-term, one that aims to change systems and attitudes in the community in fundamental ways.

A CHIP’s biggest drawback from the point of view of the Community Tool Box is that, although it incorporates people from all sectors, it sees the process as being initiated and led by health or public health professionals. However, a community doesn’t necessarily have to accept that particular aspect of the model, and can choose to establish a more collaborative process. Indeed, a CHIP should involve all stakeholders, from those who are most affected by the issues, to those who will be indirectly affected by an intervention, to those who control policy and/or have influence in the community, to citizens who are interested simply out of concern for the public good.

Implementing a CHIP is different for each community, but IOM provides some guidelines:

• Communities should base a health improvement process on a broad definition of health and a comprehensive conceptual model of how health is produced within the community.
• A CHIP should develop its own set of specific, quantitative performance measures, linking accountable entities to the performance of specific activities expected to lead to the production of desired health outcomes in the community.
• A CHIP should seek a balance between strategic opportunities for long-term health improvement and goals that are achievable in the short term.
• Community coalitions guiding CHIPs should strive for strategic inclusiveness, incorporating all individuals, groups, and organizations that are either stakeholders or can contribute to the process.
• A CHIP should be centered in a community health coalition or similar entity.
• State and local public health agencies should assure that a community health improvement process is in place in all communities.
• State health agencies, in cooperation and collaboration with local health departments, should assure the availability of community-level data needed for health profiles.
• States and the federal government should require that appropriate private entities report standard data on their enrolled populations, to facilitate the CHIP.

In addition, using the CHIP model, the steps to implementation might be:

• Assemble a broad-based, inclusive, participatory coalition or coordinating council to guide the CHIP process, if one does not already exist.
• Do your research.
• Identify the issue(s) you’re going to work on, if you haven’t started with a specific issue in mind.
• Analyze the issue(s) carefully.
• Take stock of potential resources, particularly those already available in the community.
• Develop a strategic plan and action plans to carry it out.
• Agree on who will be accountable for which parts of the plan.
• Work out how accountability will be monitored.
• Implement your strategy.
• Monitor both the process and the outcomes of your effort.
• Maintain your gains.
• Start the cycle again, with another issue.