heard the cannonk report or seen the handbills announcing the new order.." The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) announced its Agenda for Change in 1986, and has stated that the "philosophical context" for the Agenda for Change is set by the theories of Continual Quality Improvement (CQI).1 During the past six years, the JCAHO has convened a number of expert panels to develop the necessary tools to systematically review and revise the standards by which hospitals are accredited, and to develop methods for the implementation of CQI in hospitals. Many of these efforts are expected to be reflected in the 1994 Accreditation Manual for Hospitals, to be published in less than two years. What is CQI, and why is it being promoted? For many years, efforts to assure the quality of hospital care depended on simple, predominantly structural standards that gauged whether hospitals were organized in such a way that quality care could be provided. The second era, incorporating the 1970s and 1980s, has been marked by the enumeration of complex standards by the government, insurers, and others. When these procedural standards were met, care was considered to be of acceptable quality and no further action was indicated. When a standard was not met, the response often was to seek a miscreant who could be punished for the transgression. Attention was directed almost exclusively to the performance of physicians, with little recognition given to the roles of other participants in the process or to the organization of the process itself. The definitions of quality rarely encompassed such considerations as patient satisfaction or the needs of families, employers, or other healthcare providers. An alternative approach to attaining quality has achieved widespread use and acceptance over the past 50 years, although it remains unknown to most healthcare workers. This alternative approach is often referred to as continuous quality improvement, total quality management, total quality control, or industrial quality control.