Quality does not exist in a vacuum. It is shaped by the sweeping societal changes and forces that affect the way people work and live, industries and economies operate, and how technology is used. When context changes, the ways in which we think about healthcare, quality and leadership need to change as well. This is the final article in a series that sets out a bold and multi-dimensional view of quality that is built around the themes of human centricity, trust, resilience, sustainability and prosperity. As themes are explored, specific shifts required to move us toward Quality 5.0 are described, ways of measuring and monitoring progress are proposed and a new set of leadership competencies for the future is presented. Together with the previous five articles in this series, this article is meant to inspire change that improves outcomes at individual, community and system levels.

Introduction

Health systems are at a crossroads in the post-COVID-19 era, facing an urgent imperative to improve quality of care worldwide. Decades of efforts in expanding access to health services globally have not been matched by progress on quality. The Lancet Commission on High-Quality Health Systems exposed a stark reality: an estimated 5–8 million lives are lost each year in low- and middle-income countries (LMICs) due to poor quality care. This accounts for about 60% of deaths from conditions amenable to health services (Kruk et al. 2018). In other words, in many settings, poor care has become a greater barrier to reducing mortality than lack of access. These dismaying figures have scarcely improved in recent years. If anything, the COVID-19 pandemic has underscored and exacerbated the global quality crisis. Core health indicators have yet to fully recover from the pandemic, with many populations still struggling physically and mentally. While some high-income countries have seen gradual rebounds in outcomes, globally, the pace of quality improvement remains far too slow.

Furthermore, multiple analyses since 2020 reach a sobering consensus: the world is not on track to deliver “healthcare that is safe, effective, timely, efficient, equitable and people-centred” for all, as envisioned in the Institute of Medicine's (IOM) quality framework (IOM [US] Committee on Quality of Health Care in America 2021). A 2023 collection on global quality of care noted that efforts to measure and improve quality have proliferated, yet these often are piecemeal and not sustained. Health systems struggle with weak management capacity, lack of accountability and difficulty in demonstrating impact. Community engagement in co-producing quality care is still sporadic. The COVID-19 crisis further revealed how fragile quality can be during emergencies, from lapses in infection control to disruptions of essential services. In short, the pandemic illuminated and amplified longstanding quality gaps in every region of the world (BMJ et al. 2023).

The Canadian context illustrates both the urgency of recommitting to high-quality health systems and emerging opportunities. Despite some of the highest healthcare spending in the Organisation for Economic Co-operation and Development (OECD), our health systems are under pressure with increasing demands, increasing costs and declining, inequitable access to high-quality care. This situation is not unique to Canada; other systems are tackling the same issues. What makes them different is the way in which problems are being solved. Big ideas, bold actions and brave stewardship are essential for lasting success.

It is easy to feel overwhelmed as a leader today when the traditional focus and approaches for quality are no longer sufficient. Micro solutions are still required, but we need to broaden our perspectives and networks if we are to break free from silos and systems that reinforce the status quo. We can choose to see the future as a series of endless, unsolvable problems. Alternatively, we can navigate obstacles while creating health systems that are co-produced, sustainable, resilient and trustworthy where everyone prospers.

While quality improvement pilot projects proliferate, learnings are rarely scaled or sustained. This results in repeated mistakes and short-lived impacts. It is no wonder that progress can feel elusive and almost impossible to achieve. So, what will it take to design and deliver change that helps save and improve lives over the long term? And what will the future look like when we are successful?

This series on the future of quality was designed to stimulate dialogue, inspire ideas and challenge conventional wisdom. Each article tackled a specific challenge to be addressed – weaving together the pillars of quality that we believe have the power to transform healthcare and health systems at all levels.

Looking Back Before Leaping Forward

Quality improvement science, medicine and healthcare delivery models have evolved in parallel to the major industrial revolutions that shaped society since the 1800s. Technological advances, shifts in workforce dynamics and public policy trends all evolved from the first era of mechanization to eras of mass production, automation and digitalization. According to the World Economic Forum and others, the fifth industrial revolution, also known as Industry 5.0, is already underway. It is the next big step in bringing people and technology closer, not just for efficiency, but to create more meaningful, personalized and sustainable solutions to the world's big problems. It is this blending of technology with empathy that will enable us to tackle the most pressing, complex problems in more dynamic, human-centric and adaptive ways. Where the previous era focused on technology adoption to drive productivity and efficiency, this fifth era will see “a more profound integration of human wisdom and advanced technology to achieve personalized customization, flexible production and sustained development” (Liu et al. 2024). We are already witnessing robotics, precision medicine and artificial intelligence (AI) being used to generate innovative solutions in healthcare delivery. For example, robotic-assisted surgery and customized implants in orthopedics are enabling improved clinical and patient-reported outcomes. Concurrently, social prescribing is growing – connecting patients to community activities, social supports and lifestyle changes that support overall health and well-being. Just imagine if the power of these transformative forces was combined and scaled to improve the health of entire populations.

The Five Themes of Health Quality 5.0

If Industry 5.0 is ushering in the next big shifts in society, what does this mean for the future of quality? Quality cannot be looked at in isolation from its broader societal context, and hence the naming of this next era from a quality perspective needs to be Health Quality 5.0. In writing and researching this series of articles, five interrelated themes emerged as the pillars of Health Quality 5.0 (Table 1). The following sections will explore these themes and offer guidance for leaders on how to actively shape future-ready, inclusive health systems positioned to improve societal well-being.

Human centricity is the foundation of Health Quality 5.0. In our view, achieving human centricity means empowering patients, providers, administrators, policy makers and communities as active partners in shaping and driving quality of care. Inclusive co-creation leverages the collective insights of a population and is useful as both a strategic approach and an operational method to improve healthcare. By placing people at the heart of every decision, we rebuild trust and resilience and can forge a path toward lasting prosperity for current and future generations.

Trust is essential for health system transformation. Yet, as leaders, we know that trust can be hard to earn and fragile to maintain. Inclusive engagement, transparent communication and honouring commitments are key to fostering trust among patients, providers and communities. During crises, such as the COVID-19 pandemic, high public trust led to better outcomes, while gaps in trust, caused by misinformation and inconsistent messaging, hindered optimal care (Bollyky et al. 2022, Edelman 2022; Edelman Trust Institute 2024). A trustworthy health system listens and communicates clearly with its people, involving them in decisions and addressing equity and discrimination (OECD 2024; Peters 2024). Trust is vital for building a more resilient, sustainable and prosperous society.

Resilience is a cornerstone of future-ready health systems. Achieving resilience means ensuring that health systems can prevent, withstand, recover and learn from shocks. It requires workforce capacity and capability, high-reliability learning environments and digital enablement. The World Health Organization reinforces that we should be nurturing investment in resilient health systems that provide high-quality services because these are the foundations of social, economic and political stability (WHO 2022). Resilience relies on robust information systems and intelligent use of data to deliver timely, proactive, personalized and predictable care that meet population needs and expectations. Digital enablement through data analytics helps optimize resource allocation, clinical decision-making and outcomes. Leaders who embrace digital transformation will better anticipate needs and accelerate improvement. Robust data infrastructures, integrated systems and ongoing learning enable leaders to quickly and effectively respond to public health emergencies, workforce shortages or environmental threats.

Sustainability in Health Quality 5.0 encompasses social, environmental and economic stewardship so that everyone benefits from universal care now and for future generations. This requires communication, inclusive engagement and addressing the social determinants of health – such as access to education, housing and food security. This vision relies upon strong leadership, equitable policies that promote holistic health and collaboration between public and private sectors. It also means that innovations must be responsive to local needs and values to deliver quality that reflects individual and community perspectives. This inclusive, community-driven approach transforms health systems into engines for positive social change, fostering environments where everyone can participate meaningfully and benefit equitably. Environmental and economic sustainability are equally critical, as they anchor the long-term prosperity of both people and the planet. Reducing emissions and conserving resources are essential strategies to mitigate the consequences of the 4.6% of global greenhouse gases attributable to healthcare globally (Clarke et al. 2025; Romanello et al. 2024).

Prosperity results when a robust, equitable health system and a healthy, skilled workforce drive both the well-being and economic vitality of society. When people are healthy, they can fully participate in work, caregiving and community life – all of which drive better productivity and societal prosperity. Furthermore, investing in health lowers mortality and morbidity, reduces poverty and improves economies and well-being (Jamison et al. 2024). Improved health has historically led to longer lives, increased workforce participation and productivity, contributing as much to global economic growth as education (Remes et al. 2020). The 2025 ROI-Q Report demonstrated that investing in workforce development and quality infrastructure yields substantial clinical improvements and financial returns (NAHQ 2025).

Together, these interrelated pillars of quality provide a framework for action to achieve better health and higher-performing health systems. Health Quality 5.0 goes beyond other models such as the “sextuple aim,” bringing a broader societal lens – in addition to a planetary lens – to quality (Alami et al. 2023). Health Quality 5.0 emphasizes co-creation, collective impact and adaptive systems and learning. Health Quality 5.0 also reflects broader societal shifts that transcend traditional health sector boundaries, expanding the scope of ideas that can be applied to enable transformative change.

What Shifts Will Move Us Toward Health Quality 5.0?

Moving forward, some fundamental shifts are required. The shifts that we see as necessary to advance toward Health Quality 5.0 are listed in Figure 1.

How exactly do we go from idea to execution? Health Quality 5.0 requires serial transformation – it would not happen with episodic, incremental pilot projects that tinker with the status quo. It also would not happen without clarity of purpose, passion and the pursuit of bold, well-defined goals. As put forth in the fourth article (Thompson 2025a), a counterforce is needed to lift us out of the day-to-day noise, and to question, disrupt and imagine a better future. This is not about yet another restructuring or superficial solutions – it is about redesigning systems for a lasting impact, or in other words, building systems for quality.

We recommend a holistic innovation approach that balances desirability, feasibility and viability – drawing on Heather Fraser's three-gear business design model (Fraser 2019). This method starts with empathy and deep understanding of users' needs, moves to turning insights into actionable ideas through rapid prototyping and culminates in strategy and activation to ensure that co-created solutions are viable, scalable and aligned with organizational goals (Fraser 2019). It is a proven methodology that we see as fit for purpose with our journey toward Health Quality 5.0.

As we learned from previous articles, we have more than enough ideas and high-quality assets at our fingertips to help close the transformation chasm. As leaders, opting out of the quality and transformation agenda is not an option. Bold leadership combined with a new set of competencies and success measures is required.

How Will We Measure and Monitor Progress?

While there is no single measure of success for each of the Health Quality 5.0 themes, we see value in identifying a small set of headline indicators to galvanize action and track progress over time. Some measures will align to more than one theme – such as patient experience relating to both human centricity and trust themes. Furthermore, while resilience measures exist, work is evolving to support robust measurement of sustainability and ROI in the context of health systems (Eckelman et al. 2024; Thusini et al. 2022; WHO 2024). Based on the international consensus and the considerations previously discussed, five metrics stand out (Table 2).

Measures such as the amenable mortality rate provide a robust outcome indicator combining health system quality and access. For instance, if hypertension and diabetes are well-managed, the deaths from stroke and kidney failure (amenable deaths) will decline. Setting targets to reduce amenable mortality rates through more effective care delivery can focus efforts on the most significant risks and improve overall quality. As previously noted, roughly 1 in 10 hospitalized patients in high-income settings suffer harm globally, and unsafe care causes millions of deaths in LMICs. The aim is to drastically cut the healthcare-associated harm rate.

While these metrics may be helpful at the macro level, further work is required to ensure that metrics are appropriate to the goals and context at the meso- and micro-level. For example, in the fifth article (Thompson 2025b), we highlighted the National Surgical Quality Improvement Program and how actions at the organizational and system level reduced surgical complications and improved patient outcomes. If scaled nationally, these efforts may help reduce the healthcare-associated harm rate.

Together, these five indicators provide a multi-dimensional view of quality in health systems. They cover mortality outcomes, safety, service performance, user perspectives and fairness. Measures of sustainability and health outcomes may be coupled to ensure balanced comparisons and highlight sustainable innovations and quality care (Eckelman et al. 2024).

Of course, beneath each metric are more specific sub-indicators (such as specific infection rates, environmental and clinical process measures) that leaders will use day-to-day to improve quality at every level of health systems. At a macro level, if these five metrics move in the right direction, we can be confident that quality is improving in health systems. If they stagnate or worsen, it is a clear warning that course correction is needed.

Time to Lead: Stepping Up for Health Quality 5.0

How does organizational-level quality improvement contribute to the broader goals of human centricity, trust, resilience, sustainability and prosperity? By implementing standardized practices, optimizing processes and making decisions based on robust data, organizations can respond quickly to emerging risks. Efforts to reduce burnout and streamline workflows help build a stable, engaged workforce, which enhances patient safety and system-wide resilience.

Real change happens at the speed of trust. Publishing quality improvement outcomes publicly, co-designing services with patients and addressing disparities foster trust locally and across communities. Operational efficiency, nurturing staff and leadership development and aligning with people-centred integrated systems enable sustainability. When hospital teams, primary care providers, and other community services collaborate, such as by adopting social prescribing practices, emergency room visits decrease, access to care improves, and communities become healthier and more prosperous.

Transparency, accountability and the deliberate inclusion of diverse voices in shaping health policy and delivery are central to Health Quality 5.0. Social participation combined with public reporting, benchmarking and learning from results is vital. Measuring and publicly sharing outcomes and experiences that matter to patients and communities drive improvement. Healthcare is constantly evolving, yet quality improvement lags without real-time data. By making quality and safety visible priorities, leaders can restore public confidence and foster a sense of shared purpose among patients, providers, policy makers and the broader community.

How do we prepare leaders for tomorrow while also reimagining what leadership needs to look like for today? We acknowledge that leadership in this era demands rapidly evolving skills and agility and that the pace of change exceeds traditional approaches to education and learning. Table 3 offers examples of the competencies we see as necessary to drive Health Quality 5.0.

As healthcare boundaries blur with other sectors, it is clear to us that health system strengthening must be rooted in systems thinking – engaging diverse partners, co-designing solutions and learning continuously. If we really want to put people first and build lasting trust, resilience, sustainability and shared prosperity in society through quality healthcare, we must prioritize workforce well-being, strengthen system capacity, communicate transparently and address the social factors that affect our health. All of these efforts will help us create health systems that are robust, trusted and ready for the future. This is how we turn health into an economic engine that drives prosperity, better societal welfare and social cohesion.

Conclusion

Quality must contribute to the health and well-being of the population, resulting in economical, societal, and personal value creation. Health Quality 5.0 is not simply a new agenda or yet another framework in an already crowded landscape. It is a bolder way of thinking that puts the drivers and goals for health quality within a more expansive context. It is also a lens through which leaders can mobilize change, and a suite of aspirations for achieving better outcomes at individual, community and system levels. It pushes the boundaries of thinking while remaining practical and rooted in day-to-day realities that impact healthcare quality and safety. We hope that you find this call to action as inspiring as we do. With this series of articles complete, our commitment is to keep the conversation going and learn from ways in which people are working with the concepts proposed to guide the future of quality in Canada, and beyond. And now the big question is: What will you do to co-create a sustainable, more resilient system that brings renewed trust and lasting prosperity for the people you serve and support?

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