Within the collaborative model, the focus is more clearly on searching for opportunities to improve the processes of work and on building in quality as an integral part of clinical practice. This philosophy has been embraced by theories of Total Quality Management (Oakland, 1989) and Continuous Quality Improvement (Berwick, 1989) and, as I will explain, is the approach we have tried to develop within the Royal College of Nursing's Dynamic Quality Improvement Programme. Its basic hallmarks are in developing humane work systems and investing in people.
Experiences of quality in health care
Although there appears to be a general trend towards explicit quality evaluation in health care, what is perhaps less clear is whether different professional groups have followed the same route and have reached the same point. In considering this point, I will briefly consider the experiences of quality in medicine and nursing, drawing on the UK experiences and referring back to the three models described.
Developments in medicine
Of all the professional groups in health care, medicine can be seen to have followed the most traditional craft-based approach to organising and managing work, with quality vested at the individual practitioner level, within the overall scope of professional practice. The competence of individual practitioners is perceived as a major factor in achieving high quality patient care. Consequently, the traditional approach to quality has strongly reflected the individual, implicit model of evaluation.
