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?

At the end of the day, it is also obvious that lending credibility to the information on quality levels is not the only objective; contributing to the improvement of quality is even more important. In the case of the early development of quality councils, the pendular trajectory followed by efforts to improve quality seems to be gravitating toward the centre: quality must be improved, not exclusively by external audits (as has been the case for decades), nor by internal continuing improvement (such as total quality processes), nor by incorporating ongoing improvement standards in accreditation systems (as was the prevalent method in the last 15 years of the 20th century), but rather through active contributions by external organisms toward monitoring, guiding and spreading information concerning the performance of healthcare organizations, with the aim of stimulating improvement and transparency in their performance.

If it is assumed, as these "quality councils" are emerging outside the healthcare institutions, that they have a common mission - to contribute to quality improvement in healthcare and supporting (not simply auditing, as in the past) the efforts of health providers - it opens up multiple alternatives, not only in their proposals, their membership, their structure and activities, but also - hopefully - in their results in favour of improved quality.

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