The medical profession has, until recently, largely dictated standards of medical practice. If doctors completed their training and became licensed by the state they were trusted by the general public to provide clinical care with minimal obligation to show that they were achieving acceptable levels of performance.

Several factors have caused this situation to change. A societal trend towards greater openness in public affairs has been fuelled by the ready availability of information in many areas of life outside of the health sector. A slow realisation of wide variation in practice standards^{1, 2} and occasional dramatic public evidence of deficiencies in quality of care^{3, 4} have led to demands by the public and government for greater openness from healthcare providers. The availability of computerised data and major advances in methods of measuring quality⁵ have allowed meaningful performance indicators to be developed for public scrutiny. The result has been advocacy for the use of standardised public reports on quality of care as a mechanism for improving quality and reducing costs.^6–8

Publication of data about performance is not, however, new. In the 1860s Florence Nightingale highlighted the differences in mortality rates of patients in London hospitals,⁹ and in 1917 an American surgeon complained that fellow surgeons failed to publish their results because of fear that the public might not be impressed with the results.¹⁰

In most developed countries there is now an increasing expectation that healthcare providers should collect and report information on quality of care, that purchasers should use the information to make decisions on behalf of their population, and that the general public has a right to access that information. Organisations in the US have been publishing performance data, in the form of “report cards” or “provider profiles”, for over …