In December 2002 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) presented its prestigious Ernest A. Codman Award to teams representing organizations in the fields of behavioral health, hospitals, long-term care, and multiple organizations. The award is given in recognition of demonstrated excellence in the use of performance measures to achieve health care quality improvement. QMHC is fortunate in being able to publish, in this issue, reports on their winning projects from two of these groups.

Sinnissippi Centers, Inc., of Dixon, Illinois, won the award in the field of behavioral health. Hayes et al. report on Sinnissippi's ongoing project designed to integrate and improve the care of patients who have two diagnoses: mental illness and substance abuse (MISA). Structural barriers resulting from the state's funding apparatus for mental and behavioral health services had impeded access of these dual-diagnosis patients to the full range of needed services. These were identified and removed or overcome. The authors describe and analyze the performance measures that were developed to track changes in the patients' functioning that eventually led to a reduced use of emergency services and a generally better quality of life.

The Greater Dayton Area Hospital Association's hospital performance project won its Codman Award by carrying out a collaborative effort involving five community hospitals in partnership with the business community and local and state hospital associations. Snow, Engler, and Krella describe the project steps that are credited with contributing to a 36% reduction in acute myocardial infarction mortality over a 3-year period. They track in detail the project's progress from, as they say, "a report card to a quality improvement program." The multi-organization approach to a community-wide performance improvement initiative is especially interesting.

In their provocative article, 'Quality Improvement and the Need for IRB Review," Nerenz, Stoltz, and Jordan address issues around the distinction between the study of phenomena to gain an understanding that may be generalizable to settings other than those directly studied and the analysis of local processes, organizations, and systems for the purpose of improving them. In practice, quality management projects in health care often involve both sets of objectives. In hospitals and ambulatory care settings, clinical research involving human subjects requires documented monitoring and evaluation by institutional review boards (IRBs). Should the same be true of studies of local organizational structures and processes employed in patient care, conducted for the purpose of improving their results (which may contribute to patient outcomes)? These studies are often referred to as 'research." The authors propose to establish criteria for distinguishing between the two kinds of study in the health care setting, arguing that a study directed toward the improvement of local structures, processes, or outcomes is not, strictly speaking, research, and should not be subjected to the requirement of IRB oversight. They recommend review of such studies by an entity other than an IRB.

In looking at the changes that have occurred in the financing and control of costs of health care over the past three or four decades, Neuhauser sees a series of revolutions. He refers to the cost-cutting efforts that reflected Medicare policies as the first revolution, overturning the traditional fee-for-service system. He describes the second revolution as 'disease management," involving clinical guidelines and evidence-based medical practice. Neuhauser calls the third revolution, the most revolutionary stage, 'Personal Empowerment." In this stage of development, the patient takes primary responsibility for his or her own good health and quality of life, employing the principles of continuous quality improvement. The spectrum of modalities of care may broaden to include more alternative or complementary care. The author goes on to explore the specific approaches that might facilitate this, with comparative cost projections. Colleen Conway-Welch, in her insightful commentary, points to the need to define alternative care and complementary care, and, if they are different, to distinguish between them.

Voicing some of the same concerns as Professor Neuhauser, Thomas C. Shields, JD, in a wide-ranging interview, holds that the country stands at a watershed in its ongoing search for an effective and equitable system for financing high-quality, widely accessible health care.

Aiello, Garman, and Morris test the proposition that patients' satisfaction with nursing care is shaped by multilevel factors, such as patient characteristics, the nature of the episode of care, and the institution in which care is provided. They point out that previous studies in which evidence of multilevel influence may have emerged focused on a single level of analysis. The authors studied variance attributable to three levels of influence simultaneously. Their results suggest that satisfaction is determined primarily by the patient and the episode of care, and that organization-level factors explain almost no additional variance.