This commentary provides an overview of the Quality Worklife-Quality Healthcare Collaborative action strategy. This strategy embraces the thinking set out by the lead papers (by Shamian and El-Jardali and by Clements, Dault and Priest) and brings to life evidence-informed management practices.

An effective and sustainable health system is an important part of Canada's current and future successes. However, many healthcare organizations are not healthy places to work. We know that healthcare providers face more violence in their workplace than do law enforcement officers (Canadian Nurses Association 2002), and healthcare professionals have the lowest levels of trust, of commitment to their employer and of decision-making influence of any occupation in Canada (Lowe 2002).

We also know that healthcare providers are absent from work due to illness or disability at least 1.5 times greater than the average of all workers (Canadian Institute for Health Information [CIHI] 2005). The cost of absenteeism is growing and is now 10% of the annual total cost of government- funded healthcare (Office of the Auditor General of British Columbia 2004). Another startling statistic is that 46% of physicians are in advanced stages of burnout (Canadian Medical Association 2003). To ensure patient care is delivered in a safe and effective manner, the health of healthcare providers and the health of their work environments must be improved.

In addition to this evidence of an unhealthy (and, thus, poorly managed) healthcare workplace, 20-30% of Canadian healthcare providers are eligible to retire in the next decade (CIHI 2005). This retirement will take place at a time of increasing demand for labour-intensive care by an aging population who will be coping with varying degrees of chronic disease.

Our elected leaders seem to have decided the road to better healthcare can be found by monitoring three healthcare indicators: waiting times, access and patient safety. They also seem to be ready to fund proposals that might lead to positive change to any of these indicators. Much less attention is given to more effectively managing the health system's main asset, our estimated one million healthcare providers. Reducing waiting times, increasing access to care and ensuring patient safety will not happen unless healthcare organizations become healthy workplaces.

Evidence shows healthy healthcare workplaces lead to better patient care. Our health system needs to embrace evidenced-informed management and accountability practices. In order to ensure more effective and focused activity to improve the quality of work life (QWL) in healthcare, we need to monitor key QWL indicators.

In their paper, Judith Shamian and Fadi El-Jardali set out valuable examples of evidence-informed management practices related to healthy workplaces. They point out that healthy workplaces benefit individual and organizational performances, as well as patient and societal outcomes. They also provide advice on what needs to be done in terms of policies and practice to encourage the health system to put in place and nurture sound management and accountability practices.

Dave Clements, Mylène Dault and Alicia Priest explain in their paper the critical role that effective teamwork has on the quality of the healthcare workplace and the quality of patient care. They note that teamwork leads to improved performance and is an essential ingredient to effective patient care. They also set out issues that need to be addressed to make healthcare teams more effective. For example, they argue that the health system needs to put in place collaborative practice training within its education programs to help the many health professionals realize the benefits of working together.

In late 2005, 11 major national health organizations decided to work together to build healthier workplaces for healthcare providers (Table 1). To do so, they created a pan-Canadian collaborative of 45 experts and asked them to develop an action strategy to improve healthcare workplaces. They named it the Quality Worklife-Quality Healthcare Collaborative (QWQHC). Leaders of those organizations recognized that a pan-Canadian approach was needed that would galvanize the health system to improve healthcare workplaces. They seek action-oriented strategies that embrace evidence-informed management and accountability practices.

One of the first steps taken by members of the collaborative was to adopt the following shared belief statements to guide their thinking: "We believe it is unacceptable to fund, govern, manage, work in or receive care in an unhealthy health workplace," and, "A fundamental way to better healthcare is through healthier healthcare workplaces."

The 45 members of the collaborative know from hard and often-frustrating experience that enormous opportunity exists to use healthcare resources more effectively and that a key ingredient is a healthy workplace for healthcare providers. They also know that there are innovative healthy workplace initiatives currently implemented within organizations and that we need to build on these experiences, share them and work together to raise the overall standards of health human resource management practices across Canada.

Through the work of the QWQHC, which will be completed in March 2007, we have developed three action strategies that embrace evidence-informed management and accountability practices. These strategies are intended to help the Canadian healthcare community work together to build healthy workplaces and link improvement to patient care outcomes.

First, we have identified a standard set of healthy workplace indicators that we think all healthcare organizations should build into their management information systems, performance agreements and accountability reports. The standard QWL indicators with standard definitions include the following:

• Two system-level indicators - provincial healthy workplace targeted funding and organizational healthy workplace program spending
  
• Seven organizational-level indicators - turnover rate, vacancy rate, training and professional development, overtime, absenteeism, workers' compensation lost time and provider satisfaction (a composite indicator based on the Canadian Council on Health Services Accreditation-Ontario Hospital Association pulse tool)

Second, we have identified priority actions that are known to improve the workplace and that can be put in place without delay. The actions focus on organizational and system-wide performance improvements. A self-assessment checklist is provided for organizational leaders to determine their strengths, areas for opportunities and potential leading practices for each priority action area. For each of these action areas, "menus" of leading practices as well as the overall recommended change process for implementing these QWL initiatives are also proposed.

Ten organizational-level action areas include putting the following in place:

• A strategic foundation for a QWL initiative
  
• Organizational data systems to track and analyze QWL
  
• Organizational structures and processes that facilitate collaborative working practices
  
• Healthy leadership support and development programs
  
• Strategic training and development programs
  
• Fatigue-management policy and programs
  
• Innovative approaches to workload and staffing systems
  
• An integrated disability prevention and management system
  
• A comprehensive support system for employee wellness
  
• A healing environment

Four system-level priority action areas include putting in place the following:

• A national QWL database and support for reporting of standard QWL indicators
  
• Enhanced performance and accountability agreements, and accreditation standards
  
• A pan-Canadian QWQHC knowledge network to recognize and share leading practices
  
• A national workplace health program for healthcare

Third, the QWQHC members have set out a framework to exchange and apply knowledge, leading practices and research on healthy workplace strategies among all healthcare organizations across Canada. In order to know where to begin and then how to succeed in implementing positive change, healthcare organizations need easy access to research, advice and leading practices. The proposed knowledge network would actively connect explicit knowledge (i.e., research findings) and tacit knowledge (i.e., front-line experiences) and would provide a "one-stop shopping" approach for individual change agents, organizations, policy-makers and researchers to connect on QWL issues in healthcare. The knowledge network would also identify existing knowledge exchange vehicles and initiatives wherever possible, and provide a clearinghouse for key target knowledge users. The knowledge would be presented in a format that allows users to find explicit and tacit knowledge for key areas that they have prioritized for action.

To expand on this further, key activities of the proposed knowledge exchange network include the following:

• Developing an actively updated central clearinghouse or website that provides links to relevant existing knowledge exchange initiatives
  
• Supporting communities of practice - bringing together and supporting the development of QWL champions in health organizations, and supporting knowledge exchange relating to priority areas for improvement
  
• Providing a "go-to person" for providing active relational engagement between stakeholders
  
• Keeping the inventory of the research for QWL up to date by building on the current database on published literature and "grey literature" documents that was used to generate the environmental scan for the QWQHC initiative; this aim is to ensure easy access to current and relevant information for all health leaders
  
• Developing an easy-to-access database of leading and promising practices in quality work life and quality healthcare
  
• Developing the capacity to respond to organizational requests for "just in time" customized knowledge products such as briefing notes, background documents, research syntheses, multimedia presentations, overviews of specific leading practices and organizational QWL options
  
• Providing skilled "scribes" who codify tacit knowledge into explicit knowledge by seeking out and sharing leading practices on how organizations create success and share knowledge and skills internally between components of large healthcare organizations

The work of the QWQHC has been shared with broadly represented groups of stakeholders at a series of conferences as well as at the pan-Canadian QWQHC Stakeholder Summit held in December 2006. The feedback elicited from each of these opportunities will be incorporated into our final action strategy, to be released in March 2007. This report will be broadly disseminated by each of the QWQHC partner organizations. Committed engagement of key stakeholders is an ongoing key activity of QWQHC members as we are actively identifying sustainable ways to bring the pan-Canadian QWQHC action strategy to life before the end of our mandate.

There is currently great momentum across the country regarding a pan-Canadian approach to addressing our health human resources (HHR) issues, as described in the Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian HHR Planning (Federal, Provincial, Territorial Advisory Committee 2005). We feel that it is important to support the sustainability of the work of the QWQHC through the integration of the proposed QWQHC action strategy into this broader HHR planning framework. The QWQHC has essentially built an evidence-informed solution to achieve one of its major HHR goals. However, until this new pan-Canadian HHR planning mechanism is decided upon, it is important that we not lose any momentum on the work of the QWQHC. Ongoing collaboration between key stakeholders will be facilitated and supported by the QWQHC's national health partners.

Improved patient care depends on a healthier work environment for healthcare workers. Waiting times, access and patient safety will get worse, not better, if we continue to tolerate unhealthy healthcare workplaces. Surely, building a healthy workplace is a more effective use of public money than paying for the costs of unhealthy healthcare workplaces.

All Canadians need to know that it is unacceptable to fund, govern, manage, work in or receive care in an unhealthy health workplace. Policy-makers, managers, health professionals, educators, researchers and unions need to work together effectively to build and sustain healthy workplaces through the uptake of evidence-informed management practices. The sustainability of our Canadian health system depends on it.

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