Citizens' quality councils: an innovative mechanism for monitoring and providing social endorsement of healthcare providers' performance?

In recent years, under the influence of continuing improvement and total quality strategies, efforts to improve the quality of healthcare have been generated from within each healthcare organization. External mechanisms, such as accreditation, that drive quality improvement from without, have existed for much longer. However, these accreditation systems incorporated the need to demonstrate the existence of continuing improvement processes as a standard barely 10 years ago; thus, the external mechanism included the development of internal processes as yet another requirement. As Dobrow, Langer, Angus and Sullivan state in the lead article, the existence of a whole evidence-based culture that has spread the concern about quality is beyond doubt; I would add that it has also intensified this concern. Several factors have contributed to this trend, which now seems irreversible. On the one hand, as the paper points out, one of these factors is the growing requirement to allocate resources according to performance. On the other, there is the growing evidence of errors committed by health systems that cause harm to patients. The latter has created increasing demand for reliable information, conceived not only to allow the detection of these situations, but also to invest greater reliability in the health systems in the eyes of patients and general public. In both cases, however, the question remains: Who defines and who measures quality levels in such a way that the information is credible?