"Although everyone seems to be talking about quality, the concept is slippery and the meaning elusive. There are several reasons for this. Firstly, it is put to different uses, to serve different purposes - and its meaning changes according to the interests that are driving it. Secondly it exists, like beauty, in the eye of the beholder: Different people experience it in different ways. This may depend on whether they are on the providing or the receiving end; it may also depend on what they need, or expect to receive." (Pfeffer & Coote, 1991, p1)
The ‘democratic approach’ to quality is emerging from the more traditional approaches as a distinctive attitude that is better suited to the modern health and welfare system. Pfeffer & Coote (1991) describe this new approach as having three core features:
- responsive and flexible,
- a system in which the public is empowered as service users, providers and as citizens.
There are a range of quality assurance activities that all claim to improve service user and population outcomes and health service efficiency. Common activities include sentinel event monitoring, accident and incident monitoring, medical record review (and other forms of audit) as well as peer review and programme evaluation. These activities perform an important function in the modern health care system but Balestracci (2009) argues that they are all focused on the negative end of performance with the aim of identifying and correcting any outliers.
In contrast, quality improvement activities (eg, root cause analysis) are more focused on the positive end of performance with the goal of understanding the underlying processes that help produce good outcomes for people. The idea is to eliminate inappropriate and unintended variation in service practices and to identify superior performance so that everyone else can learn from it.
Such QI processes are becoming a routine part of delivering effective health care. In fact, they have become so popular that the Australian National Health and Medical Research Council is currently seeking submissions on a framework to help manage the ethical issues related to QI activities in health services. Perhaps we should all take an interest in assessing how well QI activities actually deliver on their promises, how well they are governed and how compatible they are with the three core features of the democratic approach to quality.