guideline clearinghouse accessible by Internet (www.guideline.gov). The website contains information on available guidelines, compares and contrasts the recommendations of guidelines, and allows communication among those involved in guideline development and dissemination (Stephenson, 1997).

Quality Assurance: The Health Care Professional Approach

Health care providers have established systems to monitor themselves and to demonstrate quality to parties outside the profession. Several organizations have incorporated quality measures into their voluntary accreditation programs (e.g., the JCAHO), developed quality monitoring systems (e.g., the National Committee for Quality Assurance), or have published standards with which to judge cancer care providers (e.g., American College of Surgeons' Commission on Cancer).

Joint Commission on Accreditation of Healthcare Organizations

The nonprofit Joint Commission on Accreditation of Healthcare Organizations, the oldest and largest standard-setting and accrediting body in health care, has broadened its institutional coverage from solely hospitals to a wide array of delivery systems including health plans, integrated delivery networks, PPOs, home care organizations, nursing homes and other long-term care facilities, behavioral health care organizations, ambulatory care providers, and clinical laboratories. JCAHO evaluates and accredits more than 16,000 health care organizations in the United States. Application for JCAHO accreditation is voluntary. About 80 percent of U.S. hospitals participate, representing about 96 percent of all inpatient admissions.

For accreditation, JCAHO conducts an on-site quality assessment every three years. It covers such topics as patient rights, patient care, patient education, continuity of care, ongoing efforts to improve quality, safety plans, information management, and infection control. Although JCAHO (and other accrediting organizations) has traditionally focused on structural measures of quality—such as whether a hospital has appropriate capacity for the covered patient population—it now incorporates process and outcomes measures into its accreditation criteria.

JCAHO instituted the ORYX system in 1997, which requires organizations seeking JCAHO accreditation to select from among 60 performance measurement systems and two specific indicators on which they will report their care. Hospitals and long-term care facilities are being instructed to begin reporting with these indicators during early 1999. One of the systems is JCAHO's Indicator Measurement System (IMS), which has specifications for 42 quality-of-care indicators (including 5 for cancer care; Table 6.1), and others are being developed. About 40-50 hospitals currently use the IMS reporting system (Chris McCravy, IMSystem, personal communication to Maria Hewitt, 1998). With institutions choosing their own indicators, making comparisons across institutions will be challenging. It should allow for comparisons with prior years within the same institution, benchmarks, and goals. JCAHO will soon rely on the American College of Surgeons' Commission on Cancer survey findings for cancer programs within JCAHO-accredited organizations (see below).



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