Confused and confusing It's difficult to know where to begin when contemplating this paper. Let's start by wondering who it might have been addressed to. The non-specialist will be confused, because the prescription is unclear and contradictory. The specialist will be puzzled, because the language is muddled. A large part of the problem with this paper is the lack of understanding it shows about the systems and concepts of what is very loosely called quality. This incomprehension seems to be acute in the health sector, and almost every publication suffers from it. The distinctions between compliance (and audit, including the special case of clinical audit), and excellence are hardly ever made, yet they lie at the heart of clear understanding, and are key to effective action. Meeting standards - complying with sets of rules and procedures in a way that can be audited without ambiguity - is the entry-level requirement of any organisation, whatever it does, but is especially important in risky enterprises like health systems, airlines and nuclear power plants. If getting things wrong can be a disaster, then systems to minimise that are essential. At the far edges of our ability - for example, in paediatric rescue and the use of heart monitoring - the need for robust systems and the ability to review performance against standards is life critical. So, compliance is a given - a necessary cost of doing business. Performance excellence is another thing altogether, and if there is a new frontier in the provision of health services, in New Zealand and around the world, then this is where it is to be found. Many people, including many practitioners, use the Q word to label both compliance and performance excellence - muddling both up with a plethora of terms and loosely-defined concepts as though they are one and the same. They're not! So what is the new frontier? It begins with acceptance that performance excellence is inclusive and extensive. An excellent organisation; one which is competent, capable, reflective, able to learn and adapt quickly and innovate fearlessly; one that delivers world-best goods and services; does not happen by mistake. It does not arrive out of compliance and audit either. It will be investing, in every sense of the word, in leadership development, in strategy development and deployment, in it's people, and in process improvement. It will be in day to day contact with, and will be hearing the many voices of, it's customers and markets (whatever those words mean in each different case). It will manage and make use of a wealth of contemporaneous information, and it will be a beacon in it's sector. Does that sound like New Zealand's health sector, or many of our principal hospitals? In a few places, in a few services, maybe. But overall? No way. If that sort of organisation doesn't happen by mistake, how does it happen? There are two key attributes: leadership commitment (the senior leadership want it to happen, and will do what it takes to make it happen); and process. The first often comes out of crisis, the second can be delivered by any of the internationally-recognised structured approaches to excellence: here at Brilliant New Zealand Ltd we recommend and are familiar with the USA's Baldrige approach, but there are others. These approaches offer organisational diagnosis - the first step in getting well is usually taking a history - and a structure within which to accommodate all the other activities that large and complex organisations get involved with. Where does compliance fit? In the process improvement area. What about the new approaches to LEAN, and the statistically-alluring Six Sigma methodologies? Or business process re-engineering? Same place. Human resource? In the relevant category. What should you be doing about leadership? There’s a category for that. Strategy? There’s a category for that. Performance excellence offers an architecture for analysis that aligns and integrates all of the activities of an organisation. What many in the sector call quality is a subset of excellence, not an alternative.