SHEA and JCAHO: partners in science.

In the 1980s, there were dramatic changes in the United States healthcare delivery system. All interested parties began to demand greater efficiency and more objective evidence of the quality of care. It became clear to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that its historical primary focus on the structures and processes of care could assess the capability of a healthcare organization to provide quality care, but not whether quality care actually was delivered— ie, actual performance. To assess performance, it would be necessary to measure the outcomes of the organization’s processes, including patient health outcomes. Consequently, in 1986 a major transition in evaluating healthcare organizations began with the Joint Commission’s Agenda for Change. The specific objectives of this transition were: 1) revision and reorganization of Joint Commission standards, first, to reduce their number and complexity and refocus them on those clinical, support, management, and governance systems and processes, called “important functions,” that are most important to patient health outcomes, and second, to foster continuous improvement in the performance of these functions and in their outcomes; 2) improvement in the survey process to direct greater attention to the effectiveness of collaboration and integration throughout the entire organization in performing these functions and in continuously improving them; and 3) establishment of a national performance measurement system that includes uniform, objective measures of each organization’s performance and a resultant reference database that permits comparison with the performance of other organizations. This last objective will be the focus of this editorial. JCAHO began its quest for performance measurement capability by developing a series of clinical indicators. The first indicators were developed for obstetrics and anesthesia-related perioperative care. Subsequently, indicator sets were developed for trauma, oncology and cardiovascular care, and medication use and infection control. JCAHO used three main phases to develop its indicators: identification, Alpha testing, and Beta testing. Indicators initially were proposed by multidisciplinary groups of national experts that identified relevant, important, measurable processes and outcomes of care. Alpha testing of proposed indicators evaluated their face validity, established uniform data element definitions, and assessed data availability. Beta testing in 200 to 300 hospitals evaluated data element and indicator reliability, the feasibility of data collection and transmission, data analysis and risk-adjustment methodologies, the form and content of comparative feedback reports, and the validity (ie, utility) of the indicator data. Based on the Beta test, significant improvements were made in the system and the indicators themselves. On January 1, 1994, the Indicator Measurement System (IMSystem) was made available by the JCAHO for voluntary use by hospitals that want to evaluate their performance. The system includes 10 indicators in the areas of obstetrics and perioperative care; in January 1995, 20 oncology, cardiovascular, and trauma indicators will be added. Comparative data in these clinical areas soon will be available from JCAHO through participation in the IMSystem; in 1996, indicators for infection control and medication use will be added. Participa-