Frank Appel, NAQAP's representative on the Joint Commission's QI Task Force, describes the ongoing Agenda for Change as progressively defining a new vision of effectiveness in healthcare organizations. This vision, first articulated in 1989 in the Principles of Organization and Management Effectiveness in Healthcare Organizations, is based on the fundamental concepts of total quality management (TQM), the new paradigm in healthcare. The first direct outcome of these principles is a new set of leadership standards that will appear in the 1992 Accreditation Manual for Hospitals (AMH). The Joint Commission is using the mechanism of standards' revision to lead healthcare organizations into a transition to continuous quality improvement (CQI). The 1992 AMH contains a revision of the current QA standards in the direction of quality assessment and improvement standards. The transition to CQI standards will be complete by 1994, when the data-driven process of CQI will also be incorporated into information management. Major CQI revisions also will occur in other parts of the management. Major CQI revisions also will occur in other parts of the AMH. "Second generation" clinical indicators presently under development reflect the process and cross-functional orientation of CQI. TQM is seen by the Joint Commission as the next step in a logical progression in QI methods, while CQI offers answers to the weaknesses of current QA programs. Mr. Appel concludes with an outline of these weaknesses, and a strong message of encouragement to the quality professional to meet the challenge of leadership during this transition.