News reports and national polls all point to wait times as the top concern facing our healthcare system, rivalled only by patient safety. Both issues have an impact on a limited number of patients - those waiting beyond wait-time benchmarks and those receiving unsafe care. However, focusing on access and safety does little to solve the broader problem of achieving quality healthcare, which also involves discussions of efficiency, efficacy, equitability and patient-centred care, for example (Canadian Health Services Research Foundation [CHSRF] 2007a; Institute of Medicine 2001). In fact, the attention on access could theoretically be a bad thing for many patients. As Berwick (2006) points out in a recent article, "Invasive Procedures: Less Is More … and Better," less access to care often leads to improved quality of care and outcomes.

Quality of care is a serious issue. Recent research south of the border tells us that Americans receive just over half (54.9 %) of the care that is recommended for their health condition and significant quality of care variations exist across health conditions, as well as in how care is delivered (for example, lab testing, medication, surgery and counselling) (Asch et al. 2006; McGlynn et al. 2003). While Canadian data on quality care is difficult to come by, there is enough evidence to indicate that we are facing similar problems on our own turf (Clancy 2006; Schoen et al. 2005).

In other countries, major initiatives are under way to help improve quality of care. Most notable are the Quality Enhancing Interventions, which include a series of structured reviews that are a part of the larger initiative, Quest for Quality and Improved Performance - a major five-year research initiative established by the Health Foundation in the United Kingdom (Leatherman and Sutherland 2003). In Canada, although the past few years have seen the emergence of new national and provincial organizations dedicated to quality and safety (such as the Canadian Patient Safety Institute and various provincial health-quality councils), we have yet to see a national focus on improving quality. For its part, the CHSRF has adopted "managing for quality and safety" as one of four priority research themes. To guide the discussion on improving the system-wide quality of healthcare, the foundation organized two consultation processes in 2006 with key stakeholders, researchers and decision-makers.

The first consultation process was a series of interviews conducted with more than 20 key players. Interviewees told us that improving the quality of healthcare will require movement on various fronts. In particular, the key messages from the consultation include the following:

• Maintaining the status quo on performance improvement in the Canadian healthcare system will result in needless mortality, morbidity and excess cost.
  
• Decision-maker leadership incorporating evidence on healthcare quality is the cornerstone to achieving meaningful improvement.
  
• An appropriate balance of system-wide, evidence-informed interventions that target many levels must be developed and used.
  
• The opportunity exists to identify and disseminate proven management interventions to support quality improvement at the organizational level across Canada.
  
• Collaboration and complementarity among organizations focused on improving the quality of healthcare are essential.

Report from the Strategic Consultation on Managing for Quality and Safety: Collaboration to Improve Healthcare Quality (CHSRF 2007d) summarizes the discussion that came from the second consultation process, which was held in Mississauga, Ontario, on November 15, 2006, and involved about 20 participants.

In the discussion of key issues facing the quality of the healthcare system, one prevailing theme that emerged was the need to share knowledge and information within the healthcare system. Participants mentioned that healthcare organizations tend to operate in silos, with limited sharing of initiatives and information, including the area of quality improvement. These silos lead to variations across healthcare system sectors in delivery, monitoring of care and the degree of transparency and accountability that exists. Since these issues are then traditionally examined at a local level, a broader understanding of the healthcare system or comprehensive policy development is usually not feasible.

Another theme that emerged was the need to enhance patient participation in healthcare quality improvement. Participants perceived the underlying problem to be that patients and their families are not active participants in the design of the healthcare system and in the management of their own process of care.

In the same way that there is a role for patients in improving quality of care, participants saw an integral role for physician leadership. In particular, participants felt that engaging physician leaders is key for ensuring the implementation of quality improvement interventions.

Another - somewhat surprising - theme was the idea to develop and use business or financial approaches to encourage quality improvement. The short- and long-term benefits of investing in quality are not always evident to decision-makers. As a result, decision-making around resource allocation often focuses on short-term policy approaches, which are based on costs. Ultimately, participants felt there is a lack of information on the potential return on investments that decision-makers can expect from implementing quality improvement initiatives.

These themes confirm that there is no single or simple prescription for improving the quality of healthcare. To get started, the foundation has begun using the information from the consultations to inform its future agenda under the "managing for quality and safety" research theme. This agenda will focus on healthcare quality as a broader concept, which includes such dimensions as safety. The agenda is also expected to guide future commissioned research projects (including synthesis work) and knowledge transfer and exchange activities.

Collecting and sharing resources on quality improvement will be a particularly important focus throughout 2007 for CHSRF, beginning with the release of two issues of our successful research summaries programs, Evidence Boost and Mythbusters. The March issue of Evidence Boost explores how we can improve the quality of clinical decision-making for "grey zone" decisions and the quality of healthcare at large through implementing patient decision aids in the care pathway (CHSRF 2007b). And Mythbusters debunks the myth that quality rests on the shoulders of solo doctors, indicating the importance of medical teams and the role for managers in continuous quality improvement (CHSRF 2007c).

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