The Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) implemented the Agenda for Change initiative in 1986 as a major research and development effort. The focus of the initiative is the continuous assessment and improvement of patient outcomes. Measurement of the delivery of care may be assessed both through patient outcomes and related processes of care. The Agenda for Change shifts the emphasis of evaluation from an organization's capability to provide good care to its actual performance.

The specific objectives of the Agenda for Change include: redirection of the Joint Commission standards, improvement in the survey process, and establishment of performance monitoring capabilities.

There are several major aspects in the establishment of a performance monitoring system. First, performance measures need to be developed and tested for reliability and validity. Second, a mechanism needs to be established for both the Joint Commission and the healthcare organization to support data collection, analysis, and feedback. Third, a national database needs to be established that incorporates standards compliance and performance data. It is intended that the information generated by the performance data base will contribute to the continuous improvement in patient care delivery by stimulating healthcare organizations to analyze and improve processes affecting patient outcome.

The US healthcare system is being buffeted by winds of change. Once viewed as a model of excellence, economic and social disequilibrium have uncovered a multitude of frailties within the system. Spiraling healthcare costs in an otherwise stagnant economy have given rise to skepticism regarding the motivations of healthcare providers. What are the issues that confront the healthcare system? What new demands do these issues place on the delivery system? How should an organization such as SHEA position itself to meet these new demands?

Three major issues will confront the healthcare system during the next decade. First, 10% to 14% of the US population have limited or no access to healthcare. Steps must be taken through the political process to assure that every person living in the United States has access to a reasonable standard of medical care. Second, despite implicit rationing, the costs of healthcare continue to consume an ever-increasing proportion of society's resources. In response, a potpourri of strategies have been implemented to contain increasing costs. Third, as society learns more about processes and outcomes of medical care, concern for quality intensifies. Efforts to constrain costs are juxtaposed with demands to assure excellence and quality in medical care. During the decade of the 90s the critical questions will be how much medical care should be provided to whom and at what level of quality? If society insists that medical care should be provided to all who live in the United States but refuses to increase present resources, difficult decisions will have to be made regarding how to reallocate those resources and how to minimize the impact of reallocation on quality of care.

Macrolides currently account for 10% to 15% of the worldwide oral antibiotic market.' Erythromycin, the first macrolide antibiotic, was discovered in 1952 from a strain of Streptomyces erythreus obtained from soil samples in the Phillipines. Originally, erythromycin was marketed as an alternative to penicillin because of its activity against gram-positive organisms such as staphylococci, pneumococci, and streptococci. Subsequently, its clinical use broadened to include species of Mycoplasma, Legionella, Campylobacter, and Chlamydia. Although several other macrolides have been marketed in countries other than the United States, they have failed to achieve erythromycin's widespread use. Unfortunately, erythromycin suffers from several drawbacks, including gastrointestinal side effects, a short serum elimination half-life, and only borderline in vitro activity against common gram-negative respiratory pathogens such as Haemophilus influenzae.