Abstract
Background
Health professions education (HPE) is increasingly framed as a matter of social responsibility and accountability. This study examined how discourses of Total Quality Management (TQM), Quality Assurance (QA), and Quality Culture (QC) construct the meaning of quality in HPE.
Methods
A Foucauldian discourse analysis (DA) approach was conducted to examine how the discourses of TQM, QA, and QC construct meanings of quality in higher education (HE). Academic articles were systematically identified in Education Resources Information Center, and discursive patterns and power–knowledge relations were compared within and across the 3 frameworks.
Results
QC was portrayed as a participatory, value-driven approach, contrasting with QA's emphasis on external control and compliance. TQM framed quality as a strategic resource for competitiveness, mobilizing internal power toward market advantage.
Conclusions
Quality discourses function as regimes of truth that shape governance and institutional priorities. Hybrid models combining QC's cultural foundation with QA's regulatory mechanisms may support socially responsible quality development in HE and HPE.
Keywords
Introduction
Higher education (HE) is increasingly expected to be socially responsible and accountable to society, making quality a central concern. While quality has long been prioritized, its meaning remains contested and multidimensional, shaped by diverse interpretations and shifting sociopolitical contexts. 1 Today, quality is not a static concept but a dynamic construct influenced by educational, economic, political, and social environments.2–6
Within discursive landscape, three dominant concepts: Total Quality Management (TQM), Quality Assurance (QA) and Quality Culture (QC) offer distinct approaches to conceptualizing and governing quality. TQM, adapted from industrial and business management, emphasizes continuous improvement, efficiency, and competitiveness through strategic planning and measurable performance indicators. 7 In contrast, QA reflects a regulatory and accountability-oriented approach, operationalized through audits, accreditation, and compliance with external standards. 3 Here, quality is understood as conformity to predefined benchmarks, reinforcing external control and standardization. QC, emerging as a counterpoint to overly technical or compliance-driven models, foregrounds shared values, participation, and organizational learning. 8 It promotes collegiality and cultural ownership of quality processes, viewing quality as embedded within institutional practices rather than imposed externally. Together, these constructs illustrate how different discursive logics, managerial, regulatory, and cultural shape the meaning and enactment of quality in HE.4,7,8
Health professions education (HPE), embedded within HE, is similarly shaped by these discursive logics, yet the effects are often amplified by the sector's regulatory environment, the centrality of clinic practice and the direct connection to patient outcomes. Accreditation and licensure requirements, competency-based training frameworks and clinical placement governance render HPE a highly regulated domain in which quality discourses do not merely organize institutional processes but also participate in the formation of professional identities and pedagogical norms. 9
According to Chua, “quality” in education should be handled differently from manufacturing or service industries, highlighting its multidimensional and ambiguous nature.3,7,8,10 Narrowing the concept to a single definition is problematic, as some definitions lack specificity or are too general to be operationalized. 11 To examine these discourses and their underlying power knowledge logics, we adopted a discourse analytic approach informed by Foucault's conceptualization of discourse and Phillips’ text-context framework.
Given the ideological nature of these discourses, this study adopts Critical Discourse Analysis (CDA) to explore how language constructs power relations and legitimizes understandings of quality. CDA enables an examination of quality not as a neutral descriptor but as an ideological construct embedded in networks of discourse and reinforced by power. 2 Here, Foucault's concept of power/knowledge provides the theoretical lens. Rather than asking “What is quality?,” this perspective interrogates “How do truth claims about quality circulate and gain legitimacy?” Quality discourses function as regimes of truth that normalize certain interpretations, marginalize alternatives, and reproduce power relations through governance structures, audits, and accreditation systems. By revealing how these discourses operate as mechanisms of control, the study highlights the political and ideological nature of quality in HE and its implications for socially responsible education.
Methods
Methodological framework
This DA aims to answer the following research question: “How do the discourses of TQM, QA and QC construct the meaning of “quality” in HE, and what similarities and differences emerge in the power–knowledge logics underpinning these constructions?” DA is concerned with the meaning of language and text in a social context. It focuses not on the formal properties of language, but on its function, what language is used for, and how it reflects and shapes social realities. 12 DA enables the analysis of meaning in both dialogical exchanges and broader cultural patterns of representation. 13 This is done by a critical examination of articles which explains quality in HE settings. In line with Fairclough and Wodak, language is not a neutral medium but a vehicle for values, attitudes, judgments, and beliefs, and a reflection of social practices. 14 This makes DA suitable for studies in educational strategy and policy.
We adopted a macro-level discourse analytic approach. 15 beginning with an examination of how power and knowledge are embedded in language, identifying patterns that constitute institutional and societal structures. 16 Drawing on Phillips framework, we considered 2 analytical axes: (1) text versus context, and (2) constructivist versus critical approaches. These axes were treated as continua, allowing for hybrid analytical perspectives (Figure 1). 17 The first axis illustrates whether the researcher is focusing on specific texts or on the surrounding texts. These axes were treated as continua, allowing for hybrid analytical perspectives. The proximal context focused on the specialized field of HE quality discourse, while the distal context encompassed broader educational policy and cultural frameworks. 17
Illustration of a discourse analytical approach adapted to Phillips. 17
Following Foucault's conceptualization of discourse, we structured our DA around 4 core steps
18
:
Defining the research question Specifying the discourse level Selecting the material for analysis Conducting the analysis.
19
To ensure methodological rigor, we embedded this DA within a systematic qualitative research design, characterized by transparency, coherence, and reflexivity.
20
This design included:
Clearly formulated research questions Purposeful sampling of peer-reviewed academic articles Systematic identification of discursive statements Comparative reading across texts and discourses Interpretive synthesis grounded in discourse theory.
Data collection process
A systematic literature search was conducted using the Education Resources Information Center database. Search terms included “Quality assurance in higher education,” “Quality culture in higher education,” and “Quality management in higher education.” Inclusion criteria were limited to peer-reviewed articles published in English between January 2013 and March 2024, focusing on generic and theoretical discussions of QA, QC, and TQM. To maintain conceptual clarity, case studies, country-specific analyses, and implementation reports were excluded.
Policy and strategy documents were deliberately excluded, as they constitute a distinct discursive arena with different authorship, power structures, and communicative purposes. The aim of this study was to analyze how quality is constructed within academic discourse, where TQM, QA, and QC are theorized, debated, and conceptually developed. Including policy documents would have introduced heterogeneity in text genre and speaker positions, thereby obscuring the focus on academic conceptualizations of quality.
Analytical procedure
A discourse analytical approach was applied to examine how the 3 quality concepts, TQM, QA and QC construct meanings, position actors and articulate implicit power–knowledge relations within HE. The analysis followed a multistep interpretive process informed by Foucault's understanding of discourse as a system of statements that shapes what can be thought, said and done, and by Phillips’ distinction between text and context.
First, each text was read independently and examined line-by-line. During this initial reading, discursive features were marked intuitively yet systematically, including normative language (eg, should, preferred), managerial or control-oriented terminology (eg, inspection, efficiency, documentation), value-laden expressions (trust, collegiality, culture), and explicit or implicit power markers (hierarchical lines, control, accountability). These elements were treated as potential indicators of underlying assumptions, institutional rationalities and discursive strategies. To further operationalize the analysis of power–knowledge relations, specific linguistic markers were used as heuristic indicators, including metaphors signaling power asymmetries (eg, “penetration,” “climate”), normative verbs implying authority (“should,” “must”), and descriptions of organizational processes revealing control, surveillance or distributed agency. These markers enabled the identification of how discourses legitimize certain practices, position actors and establish institutional logics.
Second, relevant statements were extracted into an analytical table that included (a) the excerpt, (b) the discursive patterns of the statement, and (c) notes on how power was constructed (eg, top-down, bottom-up, shared). This step enabled identification of how each text positioned leaders, teachers, students or institutions, and how authority, legitimacy and accountability were framed.
Third, the texts were grouped by discourse (QA, QC, TQM), allowing a proximal-context comparison within each conceptual area. Within-discourse patterns were then contrasted across the 3 concepts to identify differences in how quality was problematized, governed and justified. This comparative step followed Phillips’ notion that discourses must be understood both internally (within a text) and relationally (across texts).
Reflexivity formed an integral part of the analytical process. The first author's professional background as deputy head of a physiotherapy school, experience with institutional quality processes, and teaching in leadership may shape sensitivities toward hierarchical dynamics, collegial cultures and audit-related practices. These positional influences were acknowledged throughout the analysis to ensure transparency in how interpretations of discursive patterns and power–knowledge relations were formed.
Interpretation
The findings were interpreted by synthesizing the discursive patterns identified across the 3 frameworks, with a focus on how power–knowledge relations shape their constructions of quality. This interpretive phase examined how each discourse legitimizes understandings of quality and positions actors within specific organizational logics. Guided by a reflexive stance, the analysis sought to uncover the underlying assumptions and implications of each framework for how quality is conceptualized and enacted in HE contexts.
Results
The search strategy resulted in a total of 285 articles. A flow chart is illustrated in Figure 2. Broken down by each search string, the numbers are as follows: QA generated 228 articles. After title and abstract screening, 6 articles remained, and, following the inclusion criteria of the last 10 years, this selection was further narrowed down to 3 articles. After full-text screening the study done by Vettori 21 was excluded due to its country-specific perspective and only 2 articles remained included. For Quality Management, the search produced 46 articles. After conducting a title and abstract screening, 6 articles were considered relevant, with 2 articles meeting the inclusion criteria of being published within the last 10 years. In the case of QC, the search yielded 11 articles. Subsequently, 2 articles were selected following the review of titles and abstracts, and both met the inclusion criteria of being published within the last 10 years. Table 1 provides a structured overview of the included studies, summarizing their origin, study type, focus and discursive orientation. The detailed analytical table is provided in Supplemental Table S1.
Flow chart of the data collection process.
Overview of Included Articles.
Abbreviations: TQM, Total Quality Management; HEI, higher education institute; QA, Quality Assurance; QC, Quality Culture.
The following sections present the discursive patterns identified in the analyzed texts, describing how each discourse constructs quality, positions institutional actors and articulates power relations. In line with the nature of DA, descriptive and interpretive elements appear together, as meaning and power emerge directly from the interpretive reading of the texts.
Quality culture
Discursive construction
The definitions of QC in HE, as presented in the 2 analyzed studies,22,23 share several core elements. Both emphasize the central role of leadership, with power dynamics ranging from top-down- to bottom-up approaches. A flat hierarchy and a team-oriented focus are considered conducive to fostering a positive QC. Effective communication, trust, and shared understanding are highlighted as essential components. The integration of employees into decision-making processes and the exchange of knowledge are seen as mechanisms that enhance organizational cohesion and quality development. Furthermore, shared values, employee satisfaction, and the opportunity for feedback are identified as indicators of a thriving QC. QC is portrayed as an organizational philosophy that transcends the procedural focus of QA. It is not merely a tool for achieving quality but a living model that permeates the institution. Leadership, communication, shared values, and employee engagement are the driving forces behind this holistic approach.
Quality assurance
Discursive construction
In contrast, QA is framed as a mechanism of control, often driven by external stakeholders such as accrediting agencies and governmental bodies. Ryan 24 describes QA as a tool for providing objective insights from an external perspective, yet notes skepticism toward rigid models and concerns about the erosion of staff autonomy. The international application of QA criteria is also questioned, especially in relation to cultural diversity. Yingqiang Yongjian 25 reinforce this view, portraying QA as a control system that may diminish institutional autonomy. The quantitative focus of QA, which reduces quality to metrics and scores, is critiqued for potentially misaligning with the educational mission. Both studies suggest that QA, while intended to ensure quality, may inadvertently steer HE institutes (HEIs) toward a competitive, power-driven future.
Total quality management
Discursive construction
TQM is conceptualized as a strategic and continuous process aimed at achieving efficiency, competitiveness, and customer satisfaction. In’airat and Kassem 26 describe TQM as a unifying force within the “academic industry,” emphasizing strategic aggressiveness, teamwork, and control. Leadership is again central, but here it serves to mobilize collective effort toward market success.
Papanthymou and Darra 27 highlighted potential for long-term benefits and competitive advantage, stressing the need for employee commitment. Power dynamics in TQM are framed as instrumental, with quality positioned as a resource for institutional power.
Comparison of Quality Concepts in HE
Although TQM, QA, and QC all address the construct of quality in HE, they differ significantly in their underlying philosophies, power dynamics, and operational strategies.
TQM conceptualizes quality as a strategic asset, actively developed to gain competitive advantage. It emphasizes efficiency, customer satisfaction, and continuous improvement, often within a market-oriented framework. Power is exercised internally to position the institution competitively, and leadership is typically top-down, mobilizing teams toward institutional success. QA, in contrast, treats quality as a measurable and comparable resource, primarily shaped by external control mechanisms such as accreditation agencies and governmental bodies. The focus lies on standardization, documentation, and compliance, often resulting in tensions between institutional autonomy and external accountability. Leadership here is also top-down but driven by external mandates rather than internal strategy. QC stands apart by framing quality as an emergent property of organizational culture, rooted in shared values, trust, and collegial engagement. Rather than being a tool to achieve quality, QC is a living model that permeates the institution. Quality improvement is not the explicit goal but a natural outcome of a healthy organizational climate. Leadership initiates the process but relies on bottom-up participation to sustain it. These distinctions are summarized in Table 2, which outlines the core differences in focus, power orientation, objectives, methods, and leadership styles across the 3 concepts.
Comparative Overview of TQM, QC, and QA in Higher Education.
Abbrevations: TQM, Total Quality Management; QC, Quality Control; QA, Quality Assurance.
Discussion
This study examined how the discourses of TQM, QA, and QC construct the meaning of quality in HE and how power–knowledge relations underpin these constructions. The analysis revealed that these frameworks are not neutral tools but discursive formations that shape institutional priorities, governance structures, and professional identities.
Interpretation of discursive patterns
The geographical and institutional backgrounds of the included studies provide important contextual insights. Three of the 6 included articles originate from Europe (Greece, Germany and the Netherlands), one from the United Arab Emirates, 26 one from Canada, 24 and one from China. 25 Authors from China expressed strong criticism of QA's external control, reflecting centralized governance traditions, while QC-oriented texts emerged from organizational psychology and policy advising, emphasizing cultural and relational dimensions.22,23 The TQM-related study from a market-driven contexts, such as private colleges in the UAE, framed quality as a strategic resource for competitiveness. 26 These variations align with international research showing that quality regimes are deeply shaped by national governance models, political traditions, and regulatory cultures.28–30 This reinforces the notion that no universal model can adequately address the diverse needs of HEIs globally.
Across the texts, QA is frequently associated with control, standardization and external regulation. Terms such as “penetration” and “controversy” portray QA as an intrusive force that may undermine academic autonomy. The emphasis on documentation and visibility reflects what Foucault conceptualized as disciplinary power, where surveillance and audit mechanisms function as techniques of governance.4,31
In contrast, QC was framed through relational language, such as “climate of collegiality” and “quality culture.”22,23 These terms highlight participation, shared values and communication as essential components of organizational life. From a Foucauldian perspective, QC represents a productive form of power enacted through dialogue and cultural alignment rather than through coercion. Staff are positioned as co-creators of quality, not passive recipients of managerial directives.
TQM employs market-oriented terminology, “customer satisfaction,” “success” and “competitive advantage” reflecting a neoliberal rationality in which quality is linked to institutional performance and competitiveness. Leadership appears as strategic and top-down, mobilizing teams toward efficiency and measurable outcomes. This aligns with analyses of neoliberal shifts in HE, where institutions are positioned as market actors competing for students, reputation and funding. 32
Across all concepts, quality emerges as a discursive field in which competing logics, collaboration versus control, intrinsic motivation versus external accountability, empowerment versus surveillance are continuously negotiated. These findings illustrate how truth claims about quality circulate and gain legitimacy through different mechanisms of power, supporting Foucault's view that discourses function as regimes of truth. 33
In line with previous research, quality work in HE rarely unfolds through a single coherent model. Instead, HEIs often draw simultaneously on managerial, collegial and cultural logics, resulting in hybrid constellations of practices and meaning-making. D’Andrea and Gosling 34 argue that quality enhancement becomes most effective when institutions adopt a whole-institution approach in which formal QA mechanisms interact with collegial values, professional autonomy and shared pedagogical commitments. Their work underscores that quality processes cannot rely solely on technical procedures or external accountability but must be embedded in the everyday practices and values of academic communities, an argument aligned with our findings on QC as an internally anchored, participatory discourse.
Similarly, Sahlin 35 highlights that contemporary universities operate under conditions of “bounded autonomy,” where managerial, audit-driven and collegial models coexist and compete for influence. This perspective helps explain why hybrid forms of TQM, QA and QC emerge: while external accountability mechanisms constrain institutional autonomy, internal collegial norms and professional identities continue to shape how quality work is interpreted and enacted across organizational levels. Our findings resonate with this interplay, showing how HEIs negotiate between collaborative and control-oriented logics, and how leadership becomes a key mediating force in managing these hybrid configurations.
Implications for HE and HPE
Understanding these discursive constructions has direct implications for HEIs, including HPE. HPE programs operate within the same accreditation and governance structures as other HE fields and thus are influenced by these broader discursive logics. Recent work in HPE highlights similar tensions regarding QA: accreditation and licensure processes often struggle to balance standardization, institutional autonomy and meaningful quality outcomes. However, HPE adds complexity through professional regulation, clinical practice requirements and patient-centered outcomes, making the choice of quality framework consequential.
In this context, HPE can be understood as a discursive arena where academic, clinical and regulatory rationalities intersect in particularly pronounced ways. Accreditation requirements, competency-based frameworks and patient-centered accountability systems generate dense networks of documentation, visibility and evaluation that resemble what Foucault describes as disciplinary power, structuring what is thinkable, valued and enacted within professional education. Conversely, QC's emphasis on trust, collegiality, feedback and shared meaning aligns strongly with the relational and reflective nature of clinical learning. TQM-oriented rationalities circulate where efficiency, calculability and performance metrics intersect with professional expectations, illustrating how neoliberal logics shape HPE through managerial techniques and outcome-focused accountability. HPE thereby provides a vivid example of how QA, QC and TQM function as overlapping regimes of truth that configure pedagogical, ethical and organizational expectations within professional training.
The analysis suggests that staff values, generational expectations and disciplinary cultures should inform the choice and implementation of quality models. While QA cannot and should not be abandoned due to regulatory requirements, it may be more effective when reframed as a collaborative process that involves staff in shaping criteria and interpreting standards. A hybrid model could be beneficial: QC as the cultural foundation, fostering trust and shared meaning, and QA as a supportive and transparent mechanism embedded in shared decision-making. Such an approach would require accreditation agencies to act less as external enforcers and more as partners in quality development. Leadership emerges as a central element across all 3 concepts, though none of the texts offers concrete guidance on how leadership should be enacted in practice. Future research in HE and HPE should explore context-sensitive leadership models that align with institutional culture and chosen quality frameworks.
Finally, geopolitical variation remains a critical consideration. Quality frameworks are negotiated within national ideologies, governance traditions and economic priorities, meaning that global models must be adapted, not simply adopted to fit the realities of specific systems.
Limitations
This study is limited by its exclusive focus on academic literature, which may bias the discourse toward the perspectives of educational researchers and providers. Policy and strategy documents were deliberately excluded to maintain conceptual coherence, but their inclusion in future research could provide insights into how quality frameworks are formalized in regulatory contexts. Additionally, the inclusion criteria, peer-reviewed articles published in the last 10 years and without country-specific focus resulted in a small sample size and may have excluded relevant insights, especially regarding QA in politically diverse or rapidly evolving HE systems. Future studies should integrate policy texts and empirical data to examine how these discourses interact in practice and explore hybrid models that balance compliance, strategy, and culture.
Conclusion
This DA examined how the discourses of TQM, QA and QC construct the meaning of “quality” in HE and how their underlying power–knowledge logics differ and converge. The analysis shows that each discourse mobilizes a distinct rationality: QC frames quality as an emergent cultural property grounded in shared values, collegiality and distributed power; QA constructs quality through external accountability, standardization and surveillance; and TQM approaches quality as a strategic, efficiency-driven asset embedded in managerial and competitive logics.
Across these discourses, leadership and staff engagement appear as shared concerns, yet the mechanisms through which actors are positioned differ markedly. QC enables participatory and productive forms of power, QA relies on disciplinary power enacted through documentation and audit practices, and TQM draws on instrumental power to mobilize organizational performance. These distinctions reflect broader geopolitical, organizational and cultural conditions that shape how quality is understood and enacted within HE systems.
Despite their divergences, the discourses share a common institutional preoccupation with demonstrating improvement, legitimacy and stakeholder responsiveness. From a Foucauldian perspective, they represent competing but partially overlapping regimes of truth that define what counts as quality, who may define it, and how it should be governed.
For practice, the findings suggest that HE institutions may benefit from intentionally combining discourses rather than adopting one model in isolation. A culturally grounded QC perspective can provide the foundation for shared meaning and engagement, while QA mechanisms may serve a supportive, not dominating function when embedded within participatory structures. Understanding the implications of these discursive logics is also relevant for HPE, where similar tensions between autonomy, regulation and cultural expectations shape how quality frameworks are implemented.
Future research should examine how these discourses interact within real institutional settings, how leadership mediates between cultural and regulatory logics, and how geopolitical contexts influence the dominance of quality discourses.
Supplemental Material
sj-docx-1-mde-10.1177_23821205261428940 - Supplemental material for A Discourse Analytical Approach Focusing on Quality in Higher Education
Supplemental material, sj-docx-1-mde-10.1177_23821205261428940 for A Discourse Analytical Approach Focusing on Quality in Higher Education by Matthias M. Walter, Evert Zinzen and Slavko Rogan in Journal of Medical Education and Curricular Development
Footnotes
Acknowledgments
We have no acknowledgments to make as there was no external funding or support for our research.
Authors’ Contributions
Matthias M. Walter and Slavko Rogan originated the concept, while Evert Zinzen provided supervision and substantial input. All authors have reached a consensus on the current manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Availability of Data and Materials
All data generated or analyzed during this study are included in this published article.
Supplemental Material
Supplemental material for this article is available online.
References
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