Quality is more important than quantity. One home run is much better than two doubles.

Steve Jobs

The Institute of Medicine described 21st century quality care as safe, effective, patient centred, timely, efficient, and equitable (Aspden et al. 2004). Further, the Committee on the Quality of Health Care in America (2001) posited that patient safety should be "indistinguishable from the delivery of quality health care" Bringing a variety of perspectives to bear on the quality of care dialogue, in this issue our authors highlight nursing leadership strategies, competencies, and obligations to ensure quality and safety in Canadian healthcare organizations.

Regardless of setting, we persist in maintaining a focus on negative outcomes such as error, harm, morbidity and mortality outcomes. Moreover, measures such as length of stay, alternate level of care days, procedural wait times and costs of care remain the prevailing proxies of system efficiency, and a quality euphemism for some. But let us be clear, doing things efficiently does not equate to reducing variation, mitigating risk or optimizing care outcomes. We need to complement, if not replace, some of these long-standing indicators with ones that are truly reflective of care quality. Metrics framed in the context of individuals' actual clinical care experiences including functional capacity improvements, efficacy in the management of symptoms across the care continuum, readiness for discharge, care recipient and provider experiences, and the effective communication of meaningful details between care providers to support transitions of care are long overdue. Initiatives such as the Canadian Health Outcomes for Better Information and Care (C-HOBIC 2018) offer examples of positive patient focused metrics but as yet this suite of measures have been adopted by few healthcare organizations in the country. Although many of these outcomes have long been monitored, measured and reported in healthcare settings, variation in their measurement and documentation persists. The adoption of consistent approaches to the measurement and documentation of such outcomes within and across sectors of care has the potential to depict a true reflection of value for money invested in Canadian healthcare across the country. Nurse leaders have an opportunity to unite and advocate for the consistent use of alternative measures that truly reflect the quality of healthcare delivered in all care settings.

Given her expertise in this area, Jeffs (2018a) provides us with three complementary papers that set the context for this issue. She calls on nurse leaders to engage in authentic, complex and resilient leadership to meet the evolving challenges and advances in technology in healthcare in order to achieve the quadruple aims of: (1) improving the care experience, (2) improving population health, (3) reducing the cost of care and (4) improving the provider experience as described by Sikka, Morath and Leape (2015).

Jeffs et al. (2018) also report the findings of a study designed to explore nurse executives' understanding of the key concepts and strategies associated with patient safety and quality improvement, and their engagement with same in their hospitals and healthcare systems. The findings from an exploratory qualitative study, includes three themes of import to the sample (n = 20) of Ontario nurse executives: (1) being a strategic and system thinker while possessing the emotional intelligence to influence staff; (2) building credibility and relationships with point-of-care staff, board of directors, and leadership team; and (3) creating a culture of safety and high reliability. The findings from this study may be instructive for nurse leaders at all levels and support the development of their quality and safety literacy.

Finally, Jeffs (2018b) highlights the perspectives shared in her interviews with Chris Power, chief executive officer of Canadian Patient Safety Institute (CPSI); Michael Villeneuve, chief executive officer of the Canadian Nurses Association (CNA) and Judith Shamian, past president International Council of Nurses (ICN) and former CNA president. Their reflections depict what Jeffs describes as the "quality-safety quagmire" and identifies the need for nurse leaders to: (1) be courageous and vigilant; (2) engage patients and build coalitions; and (3) understand and navigate the science of quality, safe care and work environments.

Purbhoo and Wojtak (2018) build upon the patient-centred care concepts described by Sharkey and Lefebvre (2017). They identify how nurses can lead health system transformation by working with patients and families to co-design changes and achieve a higher quality, more integrated and patient-centred home and community care system. Consistent with the views of this editor, their perspective underscores the need to shift away from current metrics that focus on processes rather than quality of care, health outcomes, and patient/family experiences.

In view of the increased focus on outcomes and quality measures, Cleverley et al. (2018) describe the development of a Client Care Needs Assessment tool for use in mental health and addictions settings. They advocate for the matching of client care needs to nursing and inter-professional team competencies as a critically important aspect of improving and optimizing the quality and safety of clinical service delivery and care.

Lukewich and colleagues (2018) describe the lack of clarity about the role of family practice nurses and the variability in their integration into primary healthcare settings throughout Canada. They describe the consequences of their under-utilization and the opportunities missed for them to contribute to high-quality patient care. Efforts to develop a defined set of national Canadian family practice nursing competencies are being driven by the opportunity to further advance quality care delivery in primary care settings.

Collectively the papers in this issue substantively contribute to our understanding of the directions needed to strengthen the underpinnings of safe, quality care. I challenge you to contemplate additional strategies to further our knowledge about what drives and contributes to quality outcomes in Canadian healthcare settings. As nurse leaders, consider what you can do to shift the prevailing practices and measures that are used to monitor and approximate quality. Just remember it's not about the getting the most hits but successfully reaching home plate that wins the game.

Lynn M. Nagle, PhD, RN, FAAN
Adjunct Professor
University of Toronto
University of New Brunswick
Western University

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