An important complement to HEDIS has been a 10-year program to develop a family of patient survey instruments under the leadership of AHRQ (AHRQ, 1998). Working with a consortium of private-sector research organizations (including Harvard Medical School, Research Triangle Institute, RAND, and, more recently, the American Institutes for Research), AHRQ released the Consumer Assessment of Health Plans Survey (CAHPS) instrument in 1997 to capture consumer assessments of care received. The original CAHPS survey is now required by NCQA for health plan accreditation, and is used by many public and private purchasers (e.g., CMS’s Medicare program, many state Medicaid programs, the Federal Employees Health Benefit Plan, and many private employers and business coalitions), as well as quality oversight organizations. The CAHPS family has expanded to include a survey of behavioral health services, recently developed with support from AHRQ and the MacArthur Foundation (CAHPS Survey Users Network, 2005; Shaul et al., 2001). The CAHPS program has also evolved to to include various settings of care, and the acronym now stands for the Consumer Assessment of Healthcare Providers and Systems. A version of CAHPS for hospitalized patients has recently been completed (AHRQ, 2004). Other survey instruments are in various stages of development. These include both a health plan survey and a clinician and group survey (developed through the Ambulatory CAHPS process) and two versions of a nursing home survey—one for residents and the other for family members and others who visit residents regularly (CAHPS Survey Users Network, 2005). Also under development is a survey for patients receiving in-center hemodialysis treatment (CAHPS Survey Users Network, 2005).

In the area of hospital care, both the Department of Health and Human Services (DHHS) and JCAHO have played important roles. The development of standardized performance measurement and public reporting programs for hospitals dates back to 1986, when the DHHS Health Care Financing Administration (now known as CMS) released comparative reports on hospital mortality (HCFA, 1987). Also in the mid-1980s, JCAHO developed and field tested six sets of standardized performance measures (perioperative care, obstetrical care, trauma care, oncology care, infection control, and medication use) and announced its intent to require accredited hospitals to collect and submit data on these measures (JCAHO, 2005d). Both of these early efforts were abandoned in the face of strong objections from the hospital sector and others.

In the late 1990s, JCAHO embarked on a second effort to implement performance measures as a condition of accreditation for hospitals, long-term care organizations, networks, home health agencies, and behavioral health care organizations. Health care organizations were allowed great discretion in selecting measures from a large menu, and the measure specifications were not standardized (JCAHO, 2005d). In 2002, JCAHO intro-



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