Recommendations Nos. 4,5,6, and 7 in the IOM report call for structuring the agencies to oversee a program of continued improvement; this certainly appears to be necessary.

Recommendations Nos. 8 and 9 call for adequate resources through the office of the Secretary of the Department of Health and Human Services to provide research funds to support development of clinical practice guidelines and adequate educational activities to enhance the nation's capacity for improved quality of care. Funds are urgently needed at this time to support the development and testing of performance indicators.

Recommendation No. 10 calls for appropriate funds to carry out the recommendations.

The primary suggestion that I have is to develop a strategy to encourage government agencies and private agencies, such as the JCAHO, to work together—much as the Health Care Financing Administration and the JCAHO work together at present with a deemed status mechanism or as the LCME, the Residency Review Committees, and the specialty boards in the private sector carry out the quality assurance functions in medical education. I believe this would produce better results than government working alone.

The patients cared for in hospitals that are not currently accredited by the JCAHO represent a special problem. It may best be addressed as suggested in the report with cooperative efforts, particularly between the private sector JCAHO and government agencies, to develop and utilize a mechanism for nonaccredited institutions to be monitored through performance standards that employ clinical indicators.

I think this is an excellent report and believe it points in the right direction: improvement on a continuing basis by using clinical indicators and monitoring methods to provide for our citizens the highest quality of health care that is possible. The next steps should be (1) to develop a strategy to enable adequate funding for development and testing of performance; (2) to develop a strategy for utilizing the private sector initiatives (e.g., JCAHO, ABMS, ACGME) in a combined effort to maintain and improve the quality of care; and (3) to develop a strategy to address the societal issues of resource application in health care.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. (See especially Volume I, Chapter 5 for a discussion of the Joint Commission's accreditation activities and Volume I, Chapter 12 for an explication of the IOM committee's recommendations.)