tion control and surgical and anesthesia services. In addition, quality assurance was made a separate condition.

The new Conditions of Participation took effect September 15, 1986. They were accompanied by interpretive guidelines and detailed survey procedures developed by HCFA to increase consistency of interpretation and application by the state agency surveyors (HCFA, 1986).

Joint Commission standards are contained in its Accreditation Manual for Hospitals, parts of which are revised each year through an elaborate process of professional consensus. With the advent of the Conditions of Participation in 1966, which were based on Joint Commission standards of the time, the Joint Commission decided to develop “optimum” standards. An explicit quality-of-care standard first adopted in 1979 has undergone continuous evolution.

In recent years, HCFA and the Joint Commission have tried to revise their standards in ways that would impel hospitals to examine and to im-