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Changing mandates of the Joint Commission on Accreditation of Healthcare Organizations, including the 11 functional standards, the nine dimensions of performance, and the interdisciplinary approach, are reviewed. One hospital, City Hospital, strategically managed this change by marrying the principles of strategic management and continuous quality improvement. The end result of this pursuit was the production of a technology--a continuum grid--that helps to address accountability for hospitalwide functions, dimensions of performance, and interdisciplinary approaches while also addressing the need for a clinical pathway of care. The use of the continuum of care grid and steps to achieve a similar technology are identified.

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Dramatic changes in the standards of the Joint Commission on Accreditation of Healthcare Organizations, as part of its "Agenda for Change," pose new challenges for health care managers. The goal of the "Agenda for Change" is to focus accreditation on the actual performance of important functions while continuously stimulating improvement in the organization's performance and outcomes of care. In 1994, seven important functions--improvement of performance, leadership, management of information, assessment of patients, education of patients and families, operative and other procedures, and treatment of patients--were identified by JCAHO. Performance, as defined by JCAHO, can be measured through observing specific dimensions, such as, availability, safety, timeliness, effectiveness, continuity, efficiency, and respect and caring. These are considered important elements in the determination of quality, value, cost, and patient outcome. In 1995, JCAHO identified 11 important functions--patient rights and organizational ethics, assessment of patients, care of patients, education, continuum of care, improving organizational performance, leadership, management of the environment of care, management of human resources, management of information, and prevention and control of infection. In addition each institution has the opportunity to decide by prioritization where it wants to devote resources. This article reports on one hospital's response to the new JCAHO initiatives.

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A hospital's mission--to influence change at the provider level--resulted in a continuous shift to improve methodologies in quality surveillance. Interdisciplinary reviews reduce burdensome processes as well as the inherent costs of time and money. Audits were streamlined or combined when appropriate, and a uniform process improved communication and respect for other disciplines.

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The Xe-133 ventilation pattern in congestive heart failure (CHF) was assessed using 24 inpatient ventilation/perfusion studies performed to rule out pulmonary embolism. Patients with histories of CHF, myocardial infarction (MI), and cardiomyopathy were included in the study. Frank pulmonary edema, pulmonary embolism, and other known lung diseases such as chronic obstructive lung disease, tumor, and pneumonia were excluded. Fifteen of the 24 patients had abnormal ventilation scans. Twelve of the 15 showed bilateral basal Xe-133 retention on washout; the remaining 3 showed diffuse, posterior regional retention. On perfusion scans, 14 of the 15 abnormal ventilation patients showed evidence of CHF such as inverted perfusion gradient, enlarged cardiac silhouette, or patchy perfusion, and all of them had a history of CHF or cardiac disease. Nine of the 24 patients had normal ventilation scans, including normal washout patterns. Seven of the nine had normal perfusion (p less than 0.01). Four of the nine normal ventilation patients had a history of cardiac disease or CHF but no recent acute MI. Bilateral basal regional Xe-133 retention, coupled with perfusion scan evidence of CHF such as inverted perfusion gradient, enlarged cardiac silhouette, and patchy perfusion pattern, appears to be a sensitive and characteristic ventilation/perfusion finding in mild or subclinical CHF.

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A case of hepatoma was diagnosed by means of radionuclide hepatic blood flow study (hepatic scintiangiography) and static liver-spleen imaging. The hepatic flow study clearly showed arterial blood supply to the right lobe of the liver and provided a strong indication for the diagnosis. Sonographic examination indicated some abnormalities but was less conclusive than radionuclide studies. Subsequent contrast angiogram, computerized tomography scan, positive hepatitis B profile, very high alpha-fetoprotein test, and laparatomy confirmed the diagnosis.

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Three cases of postpartum hepatic hemorrhage in the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELP) were diagnosed by Tc-99m sulfur colloid liver-spleen scanning. Two patients had follow-up scans. One showed rapid resolution of the hematoma on the repeat scan performed six days later, while the other showed delayed resolution on the repeat scan four weeks later. All patients received non-surgical supportive therapy with or without blood transfusion after delivery, and recovered well. Usefulness of radionuclide liver-spleen scanning in the diagnosis of peripartum hepatic hemorrhage and monitoring course of the disease is emphasized.

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The gallium scans of seven AIDS patients who cultured positive for atypical mycobacterium were reviewed. Six cultured positive for Mycobacterium avium intracellulare, while one for Mycobacterium xenopi. A patchy uptake pattern of gallium in the lungs of these patients was identified.

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100 male adults suffering from acute gonococcal urethritis were hospitalised and treated with decreasing doses from 2000 mg to 100 mg of ciprofloxacin (1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinoline carboxylic acid, Bay o 9867; designated tradename: Ciprobay). Clinical signs (burning, exudate, edema, inflammation) and bacteriology (native and culture) were assessed hourly during the first 9 h and at 12, 24 and 72 h after start of therapy. Most patients were controlled during 10 days. 99 patients showed clinical and bacteriological cure. One patient with subacute gonococcal urethritis (protocol violation) did not react on 250 mg. No postgonococcal urethritis was seen. No side effects were reported. For the acute male gonococcal urethritis a 100 mg single dose treatment with ciprofloxacin can be recommended.

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During a Tc-99m DTPA study, activity simultaneously appeared in the kidneys and in a right lateral band. This was due to an inflammatory tract and not to urinary drainage.

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Retrospective evaluation of the pituitary gland on coronal post-contrast CT scan in 251 patients demonstrated that the pituitary gland is somewhat larger in females than in males. In males, glands measuring greater than 7.7 mm should be considered abnormal; in females, a statistically significant decline of gland height occurs with increasing age, the upper limit of normal for female gland height decreasing from 9.2 cm for a 20-year-old to 6.0 cm for a 90-year-old. Focal low densities greater than 3 mm are rare in males and probably should be considered abnormal.

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Forty-eight hours after fracture of the tibia and fibula, a 27-year-old man developed the triad of findings noted in the fat embolism syndrome (neurologic changes, respiratory distress, and petechiae). An initially normal chest-x-ray, which progressed to one of bilateral fluffy diffuse infiltrates, aided in making the diagnosis. Ventilation/perfusion lung images were performed at the time of the radiographic changes and showed "matching" defects. Transcapillary passage of lipid breakdown products was considered to be the cause. While all parts of the lung showed reduced ventilation/perfusion, the upper half of the lung fields was affected more prominently, as opposed to emboli of venous origin, which most frequently involve the lung bases.

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