Introduction

Lewis Hooper (2022) has presented findings based on his research that should be of major concern to boards of directors of hospitals and regional health authorities throughout the country. Although his research is based on studies of Ontario hospitals, my experience leads me to believe that the problems and opportunities for improvement can be applied across Canada.

Discussion

For many years now, both as a senior health system executive and as someone serving in a variety of governance roles, it has been of concern to me that the phrase "quality in retreat" is, perhaps, more real than we would like it to be. That is not to say that the system does not have a multitude of so-called quality indicators that are reported on regularly to various bodies, including boards – in nice colour-coded formats, usually of red, yellow and green – and with lots of room for commentary. This has been pretty much the norm since the late 1990s when quality became the mantra, inspired by the leadership of the US-based Institute for Healthcare Improvement, the report To Err Is Human (Institute of Medicine [US] Committee on Quality of Health Care in America et al. 2000) and the findings published in Baker et al.'s (2004) report. But have we seen an appreciable level of increase in quality of care and service? The evidence would suggest not. At the same time, we have seen significant increases in funding. It begs the question about value for money.

For too long, the primary measure used to assess performance has been money. When debates get heated, it usually boils down to money. This is understandable, given that our system was based on a fundamental agreement about who pays for what. Quality has never been an explicit part of the equation until recently, and then in a limited way. In fact, there has been considerable pushback to the idea of accountability as it relates to quality. It is no wonder, therefore, that boards have, perhaps, devoted a seemingly large proportion of their time and attention to financial matters at the expense of quality. As the author points out, this is something that needs to be rectified.

Historically, legal and accounting firms, thankfully, have encouraged senior executives to participate in voluntary community service, and this has meant that we have seen a large number of lawyers and accountants on hospital and health authority boards. Quite naturally, this has resulted in board focus that has tended toward financial and legal matters. Not that these do not deserve attention, but we are now seeing a move to the development of skills matrices wherein boards identify the full scope of knowledge, skills and experience required for an optimally functioning board and recruit accordingly. This is frequently complemented by ongoing governance training of board members. Some boards go so far as to require some board members to have formal governance designation, such as that offered by the Institute of Corporate Directors (https://icd.ca/). This can only help improve the overall performance and effectiveness of hospital and health system boards in fulfilling their primary mandate of providing high-quality care and service.

Conclusion

I am reminded of a statement that Jack Kitts made to a board I was on when he was chair of the Health Council of Canada. When he was asked about the quality and the role of the board, he said: "The first important question you need to ask is ‘Is your organization providing quality care?’ The second one is ‘How do you know it?'" This is what all boards need to be asking and should continue to ask until they are confident that they have the answers they need.

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