When compared with other developed countries, Canada sits solidly in the middle of the pack with respect to the quality of healthcare available to its citizens – rarely emerging as the front runner but rarely seen to be the laggard. These are the findings of Quality of Healthcare in Canada: A Chartbook, released by the Canadian Health Services Research Foundation (CHSRF) in partnership with the Canadian Institute for Health Information and the Canadian Patient Safety Institute, and with support from Statistics Canada (Sutherland and Leatherman 2010).

But is B-level performance good enough? Driving quality and performance improvements in Canada was the focus of the fourth annual chief executive officer (CEO) forum, Metrics for Healthcare Quality: The Leader's Role, held on February 17, 2010, and attended by some 120 CEOs, policymakers and experts. Hosted by CHSRF, with the Association of Canadian Academic Healthcare Organizations and the Canadian Medical Association as partners, the conference agenda examined the role that healthcare leaders could play in improving quality. Topics covered included the following:

• Building a minimum quality indicator set
• Developing a patient charter to support a continuous focus on quality and performance improvement
• Managing health information technology to maximize health outcomes and benefits
• Examining the available levers, incentives and sanctions for improving quality

Whether a "quality charter" targeting healthcare CEOs and boards could be an effective tool to improve patient care provoked an active debate among participants and is the focus of this article. Specifically, this article provides a summary of the main messages for developing a charter. (A more detailed description of the quality charter dialogue, as well as other discussions, is available at www.chsrf.ca.) To generate discussion, Terry Sullivan, president and CEO of Cancer Care Ontario and moderator of the forum, presented a sample charter statement on quality (see sidebar). The draft is based on a charter developed in 2009 by a group of Ontario healthcare CEOs, senior health policymakers and health policy experts.

Forum participants raised a number of ideas for improving the proposed charter. Overall, they felt that a charter, as a stand-alone tool, would accomplish little by way of quality improvements. To be meaningful, the charter must be part of a package that involves standard measures, public reporting, leadership development and support, skills development at the front lines and the setting of clear targets for the health system at a systems level. Participants also felt that without the appropriate leadership, a charter for quality – as with any declaration – is doomed to have a symbolic existence. A charter can only serve to set the course. Leaders, in this case CEOs and boards, must drive the transformation in care.

Six key recommendations were put forward as areas for improvement for the charter:

1. Engage citizens. "It is for patients that we and our health systems exist," said one participant. To truly walk the talk of improving the quality of patient care, participants felt it is critical to engage patients as part of the development and framing of a quality charter. Broad citizen engagement would also help in crafting a charter that is accessible and meaningful to the larger Canadian public.
2. Engage front-line staff. Front-line healthcare professionals are the ones who "will really make the difference in quality of care in our organizations," said one participant, a sentiment that was echoed by many. Some participants said it is particularly important to engage physicians early in the process to secure their buy-in and leadership.
3. Set the bar higher – from improving patient care to improving the overall health of the population. The modern health system aims to improve population health, said many participants, and a quality charter should be built for citizens (which includes, but is not limited to, patients) and aim to improve health (which goes beyond healthcare).
4. Build in a minimum set of quality metrics on which all signatories must agree to regularly report. Many participants felt that the charter needed to go one step further, to articulate a concrete set of performance indicators on which all signatories must agree to report. Participants felt these indicators should be identified in a collaborative manner and extend across the continuum of care. Participants also felt these efforts would enhance public reporting, which fosters transparency across the system – one of the goals of the charter.
5. Rethink bonus payments for CEOs, but maintain the line of accountability for quality through the CEO's performance review. Extending additional payments to CEOs for "doing a good job" risks sending the wrong messages, felt participants. For example, it risks conveying that the CEO is the only one with an important role to play in improving quality. Participants instead preferred an accountability mechanism that links the organizational quality plan to each CEO's performance review objectives. They saw this approach as a more acceptable means of holding CEOs to account for the quality of care in their organization.
6. Incorporate an imperative to boost value for money. There may be initial costs in improving quality, but better quality has been seen as leading to cost savings and efficiencies down the line. Participants felt that a value-for-money commitment is an important element, especially in light of the current era of rising government deficits.

Conclusion

Although opinions on the value of a charter diverged, there was consensus that the time has come to address quality improvement. As one speaker noted, quality has not been a political priority, likely because politicians don't like to admit that there is a problem with healthcare quality. It therefore falls to healthcare leaders, at the delivery end, to take up the quality challenge.

If executed properly, a charter could serve as a challenge to chief executives and boards to take (and be held to) account for the quality and performance in their organizations, as well as motivate healthcare leaders to work together to articulate a set of common goals for improving quality and performance.

Supporting materials for the fourth annual CEO Forum – including a background paper, PowerPoint presentations and podcasts of invited speakers and a full report – are available at www.chsrf.ca. If you are a CEO or senior healthcare leader, mark your calendar for the next CEO Forum, taking place February 16, 2011, in Montreal, Quebec.

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