Quality remains one of the great trade-offs in Canada's healthcare system. Every person working in the system agrees with the importance of quality, and many make it an explicit part of their personal and professional missions. Today, for example, when confronted by clear evidence of poor quality in their own practices and organizations, clinicians and administrators rarely question the validity of the information and they respond quickly to solve the problems identified. At the same time, however, most clinicians and administrators believe that large-scale improvement is unaffordable.

Although quality continues to rise in importance, and nearly every study published identifies room for improvement, something stops us from achieving the high quality we desire. The work of G. Ross Baker - who led the Quality by Design initiative and, with Peter Norton, the landmark study on patient safety in Canada - lays out the challenge clearly. Every day in Canada's healthcare system preventable errors arise in hospitals, long-term care facilities and physicians' offices. These errors lead to extra costs, poor health and, in many cases, avoidable deaths. Yet the pursuit of safety and quality remains the something extra that many of the people working in our system can follow up on only at the end of a busy day.

There are a number of potent examples to the contrary in the case studies that follow. These are portraits of healthcare systems that have made the pursuit of quality and safety a core element of their strategies, a part of everyone's work and the way they differentiate themselves from their competitors. Constant improvements in quality and safety are integral to their workplace cultures and central to what is expected from everyone employed in those systems. In a presentation based on one of the following case studies, Sven-Olof Karlsson, the chief executive officer of Jönköping County Council, put it most succinctly: "Everyone has two jobs: to do their job and to do that job better." In the systems profiled in this book, quality and cost are not opposing goals; rather, quality is one of the ways to improve cost control. Moreover, these systems are not rich healthcare systems or systems that serve only the rich. The examples collected here include Canadian systems, as well as systems from the United Kingdom, Sweden and the United States that offer care to incredibly diverse populations.

The Ontario Ministry of Health and Long-Term Care (MOHLTC) provided a grant for the Quality by Design project because we believed it was important to try to identify the common elements of high-performing healthcare systems from around the world. Our sincere thanks go to the research team and to the leaders of the systems who graciously participated. The MOHLTC's Health Quality Council has defined characteristics of a high-performing healthcare system, attributes that range from equity to efficiency. Each of the systems profiled in this book strives to meet those characteristics. And each provides an example to leaders at all levels of Canada's healthcare system of how to design our structures and processes to achieve the outcomes desired by the people we all hope to serve.

None of the systems discussed in this collection presents the ideal recipe for better quality. Rather, each case illustrates that high quality results only from a mix of good incentives, helpful information technology, clear goals, accountability systems and the constant application of quality improvement techniques made possible through widespread improvement training. Moreover, each system proves that high quality is more the result of a culture that pursues quality than of any single investment or policy. The systems the Quality by Design team profiles in this book pose a provocative challenge for the rest of us because they overcame familiar obstacles in order to deliver high-quality and sustainable care every day. We must do the same.

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