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The ‘quality’ paradox: Quality in healthcare is crucial but it’s time to rethink it

We all want a quality health service – but what does this really mean? What does quality in healthcare really look like? Dr Deborah Swinglehurst has been exploring this idea for several years, curious to find out what academics, opinion leaders, healthcare professionals and members of the public really understand by the term ‘quality’ in the healthcare context.  

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As a practising GP, the word ‘quality’ is one I hear regularly, especially in relationship to an expanding range of rather demanding initiatives such as QOF (Quality and Outcomes Framework), QIPP (Quality, Innovation, Productivity and Prevention) and CQC - Care Quality Commission. However, despite this attention to ‘quality’ in contemporary healthcare settings (and its meticulous documentation and assessment) and despite there being more emphasis on professional accountability and regulation than ever before – I detect a growing sense of unease amongst my clinical colleagues about the extent to which this ‘quality’ activity really reflects or supports the kind of ‘quality’ we aspire to in our professional lives.

Originally presented at a conference in 2013 entitled ‘The Many Meanings of ‘Quality’ in Healthcare: Interdisciplinary Perspectives’, and thanks to the ongoing enthusiasm and critical insights of academic colleagues from various institutions, I’ve now had the pleasure of editing a special collection of papers with Biomed Central which offer a fascinating array of insights into the ‘quality’ conundrum. Putting ‘quality’ under the spotlight it brings together articles from diverse fields including medicine, nursing, social policy, anthropology, design, accountancy and philosophy - to name a few.

This Biomed Central collection – a combination of 15 peer-reviewed articles, commentary and editorial across six open access journals – contributes to the ‘quality’ debate by bringing together a fascinating array of ideas, messages, synergies and shared lines of argument, made possible by the flexibility of the open access publishing space and the opportunity to collaborate across a wide range of journals.  To this end, the collection is a celebration not only of what it is possible to reveal when different disciplinary lenses are brought to a complex issue like quality in healthcare, but also a celebration of the value in finding novel ways to present knowledge.

In our accompanying editorial, “Confronting the quality paradox: towards new characterisations of ‘quality’ in contemporary healthcare”, we focus on what we have called the ‘quality paradox’. This is the notion that the pursuit and measurement of quality in healthcare may have perverse consequences and could even undermine (rather than strengthen) the characteristics it seeks to assure. Counterintuitive though this may seem, this overarching paradox resonated loudly through the papers in this series, and our opening editorial aims to summarise the papers in three interlinked themes:

1) The practices of assuring quality in healthcare (highlighting the importance of studying the everyday activities of patients, clinicians, carers and administrators if we are to grasp the meaning of quality)  
2) Giving ‘space to the story’ (the importance of listening to the stories of patients, clinicians, managers and others as one way of connecting with their values, culture and life-worlds)
3) Addressing moral complexity in the clinic, the classroom and the academy (papers which focus on the ‘ethical’ dimension of quality in healthcare including the education of healthcare professionals and the conduct of research)

I invite you to read the editorial to get a taste of what is a very rich collection of articles, cast aside your disciplinary allegiances, and stray beyond those articles that seem most immediately appealing to you. This diverse collection of articles will surprise and challenge you and – I hope – encourage you to think very differently about the nature of ‘quality’ in healthcare and what this might mean for patients, healthcare practitioners and policymakers alike.

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