Two underlying themes connect the 13 articles in this issue of Healthcare Quarterly: Canada's health system was designed and built for a very different time and population and "things can be better," the last sentence in each of the three papers on medicare and pharmacare. These pronouncements may cover all health policy literature ever written, but their consequences are profound for those relying on, working in and trying to transform a health system constantly playing catch-up to meet the population's changing needs. Concurrently, this same system is grounded in bedrock principles – a belief in single-payer, universal healthcare, for instance – said to express the values of Canadians and the nature of our nation (Soroka 2007: 5–6). In that light, the understated "things can be better" carries greater weight and prompts a response. Whether seeking to strengthen primary care continuity, reduce long-term care (LTC) hospital admissions or increase prescription adherence, this issue's improvement efforts reflect a commitment to hasten that health system catch-up and meet the country's increasingly complex healthcare needs.

The demand for more care and new services is a logical outcome of the often-cited changes to Canada's population and health status: an aging demographic with increasing fragility and a multi-generational rise in the incidence of patients with multiple chronic health conditions (Muscedere et al. 2019). Although new diagnostic tools and therapeutic, pharmacologic treatments can prolong life and personalize care, service gaps and health disparities persist, as evidenced by the ICES report on rural and urban differences in risk and service utilization (Kuenzig et al. 2019) and the CIHI report on opioid harms in Canadian hospitals (Frood and Paltzer 2019). Clearly, we can – must – do better.

Special Focus on Healthcare in Canada

P.G. Forest, a leading expert on Canadian medicare who is ideally suited to open this issue of Healthcare Quarterly, introduces a trio of timely articles that parse Health Care in Canada (HCIC) survey data on public and health professional perspectives regarding pharmacare and patient-centred care. Forest describes Canada's enduring commitment to the principles of medicare, the healthcare system's proclivity for stasis and its unequivocal need for reform. He asserts that success depends on adhering to those same principles and embracing imperatives such as "collaboration, measurement and evidence" (Forest 2019).

Joanna Nemis-White and colleagues (2019) establish comprehensive, universal, federally funded pharmacare as the top priority for health professionals and the public. Their data also display an appetite for shared stewardship: pharmacare led by governments, medical academia and the pharmaceutical/biotech industries. Given implementation complexities and stakeholder support for pharmacare's shared leadership, the authors see this as a positive response.

Amédé Gogovor and colleagues (2019) report that widespread non-adherence to prescribed therapies continues for both chronic and acute illnesses. Describing it as a "dire threat" to achieving the desired outcomes of pharmacare – medicare's second stage (Rachlis 2007) – they call for strategies addressing both patient-reported resistance to adherence and "systemic failures" of Canada's fragmented approach to pharmaceutical use.

The last paper (Montague et al. 2019) reveals no shift from 2013 to 2018 in public and provider choice about what constitutes patient-centred care: readily and timely accessed, provided in a caring, respectful environment and based on need versus ability to pay. In 2018, professionals gave care supported by research and expert opinion second place, but both groups ranked measurement and feedback of delivered care and outcomes last. The authors argue that an emphasis on access could eclipse those other elements essential for monitoring system progress.

Effective Primary Care

In integrated systems, team-based primary care is the foundation for today and tomorrow; siloed healthcare is history (Starfield et al. 2005). The articles in this section are examples of acting on evidence to end fragmentation. The first (Vik et al. 2019) focuses on links between primary care continuity (variously defined) and acute care utilization and considers whether changes in Alberta are meeting expectations. The authors report additional evidence connecting primary care provider continuity to reduced use of acute care services and suggest a tie to shorter hospital stays for some chronic disease patient groups. However, they highlight that neither the quality of care nor "the extent of collaborative interdisciplinary team efforts to support patients" informs the study. New avenues of research – measuring team continuity (not simply single provider) and probing the quality of patient interactions and type of service – could be crucial to chronic care patients and those navigating numerous health and social care settings.

Grinman et al. (2019) examine efforts to integrate palliative and acute care services for LTC residents in Calgary and Toronto. They identify factors (patient, provider, system) affecting potentially avoidable hospitalizations and outline elements and changes to create an integrated system providing LTC residents with acute medical illness with an array of services and health professionals delivered where they want: in-house. This approach, which the authors emphasize must be comprehensive, coordinated and system-wide, reduces avoidable hospital transfers and associated harms to residents (mortalities and morbidities) while lessening system costs.

Caring for Seniors

This section profiles projects improving seniors' care: a toolkit for resident and family councils piloted in Alberta's continuing care sites that increased effectiveness and engagement (Parmar et al. 2019a) and an outreach campaign that generated diverse stakeholder input and determined four elements characterizing and guiding "care that honours seniors" (Parmar et al. 2019b). Provocative research findings appear in the last article based on a study probing quality performance in Ontario LTC homes from 2012 to 2017 and associated organizational factors. The authors (Wilkinson et al. 2019) use – and argue for – a new composite quality metric (Qindex) and report "significant, continuous sector-wide improvement in overall quality performance." And, contrary to previous research findings cited by the authors, this study concludes that not-for-profit and private homes perform similarly on quality, with publicly operated municipal homes lagging. It also suggests that large operators outperform small and medium-sized ones, whereas homes with fewer beds appear to have lower-quality performance levels than medium-sized and large homes.

Quality Improvement

Jeffery Gollish and colleagues (2019) showcase a mobile app targeting joint replacement patients, a growing proportion of the population. Developed by the Holland Orthopaedic and Arthritic Centre in Toronto, their patients and a health technology company, myHip&Knee provides patients with education and interactive information to aid their recovery during the critical six-week post-surgery period. Almost 2,000 users accessed myHip&Knee from October 2015 to the end of 2017, using features such as the daily health check to develop self-management skills, improve their healthcare experience and engage more. myHip&Knee also addresses provider, organizational and system issues by reducing follow-up calls to surgeons' offices and lessening demand on resources. In 2017, 71.5% of respondents reported that the app prevented one or more hospital calls about questions and information requests related to their recovery.

Engaging Stakeholders

An engaged workforce is one of the Quadruple Aim's pillars (Bodenheimer and Sinsky 2014), a fact clearly understood by Ontario's Niagara Health. After controversy and massive change – closures, amalgamation, leadership shifts, a move – the organization rallied. A single, spontaneous, independent Acts of Kindness campaign from the IT department helped fuel the renewal, sparking 25 more departments to follow suit and together generating more than 25,000 acts of kindness as of June 2019 (Rolim et al. 2019).

– The Editors


Bodenheimer, T. and C. Sinsky. 2014. "From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider." Annals of Family Medicine 2014; 12(6): 573–76. doi:10.1370/afm.1713.

Forest, P.G. 2019. "Cutting Through the Ice …" Healthcare Quarterly 22(2): 13–14. doi:10.12927/hcq.2019.25911.

Frood, J. and G. Paltser. 2019. "Types of Opioid Harms in Canadian Hospitals: Comparing Canada and Australia." Healthcare Quarterly 22(2): 10–12. doi:10.12927/hcq.2019.25912.

Gogovor, A., J. Nemis-White, E. Torr, N. MacPherson, L. Martin, J. Aylen et al. 2019. "Non-Adherence to Prescribed Therapies: Pharmacare's Existential Challenge." Healthcare Quarterly 22(2): 21–26. doi:10.12927/hcq.2019.25909.

Gollish, J.D., L. Pereira, A.M. MacLeod, A. Wainwright, D. Kennedy, S. Robarts et al. 2019. "myHip&Knee: Improving Patient Engagement and Self-Management Through Mobile Technology." Healthcare Quarterly 22(2): 63–67. doi:10.12927/hcq.2019.25902.

Grinman, M.N., T. Human, M.J. Shankel, A. Young, J. Pedulla, A. Roopani et al. 2019. "Keeping Long-Term Care Patients Out of Hospital During Acute Medical Illness: Proposal for Common Elements of an Integrated Healthcare Delivery System for Long-Term Care." Healthcare Quarterly 22(2): 40–46. doi:10.12927/hcq.2019.25906.

Kuenzig, M.E., G.C. Nguyen and E.I. Benchimol. 2019. "Rural and Urban Differences in the Risk of Inflammatory Bowel Disease and Subsequent Health Services Utilization in Ontario." Healthcare Quarterly 22(2): 6–9. doi:10.12927/hcq.2019.25913.

Montague, T., J. Nemis-White, J. Aylen, E. Torr, L. Martin and A. Gogovor. 2019. "Canada's Evolving Medicare: Patient-Centred Care." Healthcare Quarterly 22(2): 27–31. doi:10.12927/hcq.2019.25908.

Muscedere, J., C. Barrie, K. Chan, B. Cooper, K. Critchley, P. Kim et al. 2019. "Frailty and Aging: How the Danish Experience Might Inform Canada." Healthcare Quarterly 22(1): 14–21. doi:10.12927/hcq.2019.25841.

Nemis-White, J., E. Torr, J. Aylen, A. Gogovor, L. Martin, J. Mitchell et al. 2019. "Medicare's Evolution: National Pharmacare and Shared Leadership." Healthcare Quarterly 22(2): 15–19. doi:10.12927/hcq.2019.25910.

Parmar, J., J.-A. Babiuk, K. Classen, J. Hurst, A. Haq and L.-A. Sacrey. 2019a. "Establishing Effective Resident and Family Councils: A Pilot Project to Increase Family and Resident Engagement in Alberta's Continuing Care Sites." Healthcare Quarterly 22(2): 47–52. doi:10.12927/hcq.2019.25905.

Parmar, J., K. Classen, J.-A. Babiuk and L.-A. Sacrey. 2019b. "Commentary: Identifying the Underpinnings of 'Care That Honours Seniors' in Alberta." Healthcare Quarterly 22(2): 53–54. doi:10.12927/hcq.2019.25904.

Rachlis, M. 2007. "Completing the Vision: Achieving the Second Stage of Medicare." In G. Marchildon and B. Campbell, eds., Medicare: Facts, Myths, Problems, Promise (pp. 221–42). Toronto, ON: James Lorimer & Company.

Roberts, K.C., D.P. Rao, T.L. Bennett, L. Loukine and G.C. Jayaraman. 2015. "Prevalence and Patterns of Chronic Disease Multimorbidity and Associated Determinants in Canada." Health Promotion and Chronic Disease Prevention in Canada 35(6): 87–94.

Rolim, D., C. Bourque Wiley, S. Kerrigan, S. MacDonald, S. Traynor, F. Paladino et al. 2019. "Spontaneous, Grassroots Initiative Brings Niagara Health's New Purpose, Vision and Values to Life." Healthcare Quarterly 22(2): 68–74. doi:10.12927/hcq.2019.25901.

Soroka, S.N. 2007, February. Canadian Perceptions of the Health Care System: A Report to the Health Council of Canada. Retrieved September 1, 2019. <>.

Starfield, B., L. Shi and J. Macinko. 2005. "Contributions of Primary Care to Health Systems and Health." Milbank Quarterly 83(3): 457–502.

Vik, S., C. Weaver, C. Cunningham, R. Walker, R. Lewanczuk, B. Bahler et al. 2019. "Informing Primary Care Changes in Alberta: Continuity and Potential Impacts on Acute Care." Healthcare Quarterly 22(2): 32–38. doi:10.12927/hcq.2019.25907.

Wilkinson, A., V. Haroun, T. Wong, N. Cooper and M. Chignell. 2019. "Overall Quality Performance of Long-Term Care Homes in Ontario." Healthcare Quarterly 22(2): 55–62. doi:10.12927/hcq.2019.25903.