It will take years before we can understand and measure the full toll that the COVID-19 pandemic has taken on our health systems. Of the many reverberations from the pandemic, one of the most concerning implications is an increase in the rates of preventable harm. Four years of unprecedented demand on healthcare services combined with health human resource shortages and clinician burnout have pushed our systems to the brink – and are impacting our capacity to improve or even maintain standards of care.

This edition of Healthcare Quarterly highlights concerns related to patient safety and harm and introduces a focus on organizations that are defying the odds. This year, we intend to draw greater attention to this topic and include examples of organizations that have built resiliency into patient safety systems and/or are taking steps to get back on track with improvement goals. We are pleased to be able to share insights from Ross Baker, one of Canada's pre-eminent experts on the topic of patient safety, who is contributing thought leadership to the current state of patient safety and discusses why we need to be paying attention (Baker 2024). Baker's (2024) special commentary provides additional insight into the article by Harvey et al. (2024) on building a resilient patient safety culture in a large multi-site hospital, as well as a recent analysis from the Canadian Institute for Health Information (CIHI) that explores the correlation between hospital staffing issues and patient harm during the pandemic. This commentary replaces our regular featured column on Quality 2.0 from Leslee Thompson. Thompson's column will return in our next edition (see Thompson 2023, 2024).

In addition to our focus on patient safety and harm, the articles include a primer on artificial intelligence (AI) for leaders, as well as an overview of emerging leadership models. We also highlight a case study on the benefits of engaging patients in improving transitions from hospital, complemented by an invited essay on the future of co-design with patients and caregivers from the perspectives of three researchers working with Ontario Health Teams (OHTs). We conclude with our regular featured columns from our colleague Neil Seeman as well as those from ICES and CIHI (Campbell et al. 2024; Seeman 2024; St. Cyr and Mahar 2024).

We would like to thank the authors who have contributed abstracts on mental health and substance use disorder related to our recent call for papers on this topic. We are working with Ruby Brown, our special guest co-editor, to start publishing examples of teams from across Canada that are doing exemplary work in this important area. Stay tuned as we work with the authors to finalize these articles for publishing in upcoming editions.

Emerging Issues in Patient Safety

We launch this edition with an invited commentary from Ross Baker who shares his insights into the current state of patient safety and harm and related challenges in the aftermath of the pandemic (Baker 2024). Baker makes a persuasive case for re-establishing patient safety and harm reduction as strategic priorities.

Baker's (2024) commentary offers context for an article by Harvey et al. (2024) in which the authors describe how their approach to systematic formal case reviews has contributed to fewer adverse events and a resilient patient safety culture in one of Canada's largest healthcare organizations. Their success was achieved with a multi-faceted approach that includes consistent practices for reviewing critical incidents, rigorous root cause analysis and partnership with patients and families. This is an impressive example of how one organization's corporate safety culture withstood the test of the pandemic.

AI: What Healthcare Leaders Need to Know

AI is coming. It is going to change how we all work. We are told its transformative impact will be profound and rapid, but many healthcare leaders still feel overwhelmed as they contemplate the way forward in a world with AI. Senkaiahliyan et al. (2024) give readers a thoughtful primer on what AI is going to mean in healthcare. They review the essential concepts underlying AI and go on to describe some relevant case studies in the health sector. Their article is a valuable resource for anyone responsible for delivering health services who also has an eye on the future.

Emerging Leadership Models

The pandemic amplified inequities in healthcare and underlined the importance of promoting inclusion. Bhuiya and Kelly et al. (2024) share the results of their research on inclusive leadership in healthcare. Through in-depth interviews with selected healthcare leaders, they unpack what it means to be an inclusive leader and share their insights on advancing inclusive leadership as a competency. This article will be of interest to all our readers concerned with equity, diversity and inclusion in healthcare and who are looking to foster leadership teams seeking to realize these objectives.

Co-Designing Care With Patients

In addition to patient safety and harm, patient engagement is another area of healthcare that was negatively affected by the pandemic. Thoughtful engagement was much more difficult when interaction with care recipients and families was limited through reduced caregiver presence, increased use of virtual care and conversations where all parties were required to wear masks or face shields. Hahn-Goldberg et al. (2024) remind us of the mutually reinforcing benefits of patient engagement by describing case examples of engaging patients and families in a quality improvement approach to transitions of care. The authors share the results of a study called “Bridge-to-Home” launched by the Canadian Foundation for Healthcare Improvement and subsequently expanded by Healthcare Excellence Canada (Hahn-Goldberg et al. 2024). It involved the co-design of a care transitions bundle that enabled healthcare teams to provide patients and caregivers with the information needed to better manage transitions from hospital to home or community. The study underscores the critical importance of continuing to involve patients and caregivers in continuous improvement initiatives, particularly during times of crisis and change.

We delve further into the topic of patient engagement and co-design, with the invited commentary from Kuluski et al. (2024). Their commentary highlights the value of the work done by Hahn-Goldberg et al. (2024), but it also reminds us that patient engagement is not easy and there are many significant, and sometimes fundamental, contextual challenges that must be addressed to realize the full potential of patient engagement initiatives.

Innovations in Integrated Care

Launched in 2019, the province of Ontario is moving toward greater integration of health and social care through its OHT model. OHTs are intended to improve population health by advancing integrated care in local communities and are being measured through the Quadruple Aim framework (Bodenheimer and Sinsky 2014), which includes patient experience as one of the four components of the framework. Slater et al. (2024) describe one OHT's experience with piloting an approach to routine collection of patient-reported experience and outcomes data across multiple primary care practices. The authors describe key learnings about survey development and deployment, data collection and the benefit to providers of having real-time feedback on patients' self-reported quality of life and care provision. The study has implications for both individual organizations and networks of providers that seek to embed surveys into routine service provision.

Quarterly Columns

We began this editorial remarking on the toll the COVID-19 pandemic has taken on the health system, on those who use it and on those who work in it. The pandemic exacerbated health human resource shortages, accelerated burnout and pushed our healthcare to the brink. A team at CIHI, Campbell et al. (2024), share their analysis of trends in indicators of shortages among hospital patient care staff, as well as trends in indicators of preventable harm in hospitals. Their observations give further credence to our understanding that the pandemic saw significant setbacks to patient safety and harm in in-patient care and underline the concerns raised by Baker (2024) in his column in this issue.

St. Cyr and Mahar (2024) authored the contribution from ICES in this issue. They describe their population-level research on the utilization of mental health services among women who have served in the Canadian Armed Forces and the Royal Canadian Mounted Police. They find that women in defence and public safety occupations are significantly more likely to be hospitalized for mental health reasons and more likely to visit the emergency departments or family physicians for mental health reasons. Their findings raise important questions for healthcare providers serving women with defence and public security work experience, including questions as to whether their needs are being fully met. Their research findings will also be of interest to military and veteran organizations as they address ongoing concerns about inclusivity.

Finally, this issue includes our regular column from Neil Seeman. Seeman (2024) offers a thoughtful and provocative take on how we should assess performance in healthcare. Drawing on his own recent experience as a patient, he proposes that what might matter most to patients is that their healthcare and their own health condition simply be “unremarkable” (Seeman 2024: 14). He suggests that even though many healthcare organizations proclaim their achievements on selected indicators on which they stupendously outrank other peer organizations, this is not, in fact, what matters to patients. They might simply wish for okay, normal, unremarkable care – all Bs all the time.

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