ORIGINAL ARTICLE

The determinants of quality healthcare: Implications forCanadian health leadersJonathan I. Mitchell, BSc, MSc, CHE; Wendy Nicklin, RN, BN, MSc(A), CHE, FACHE; Bernadette MacDonald, RN, MScN

Abstract—The Accreditation Canada program supports organizations in delivering quality healthcare using a quality frameworkthat recognizes the complex interplay of multiple factors that define quality. This article highlights the Accreditation Canada qualityframework and how these dimensions of quality together promote quality care. Using three dimensions of quality – populationfocus, safety, and worklife – we discuss how these quality dimensions can be utilized by healthcare leaders to improve quality intheir organizations.

There are multiple determinants of health, includinggenetics, gender, physical conditions, and access tohealthcare.1 Although factors such as genetics or

gender cannot be individually influenced, access to qualityhealth services that contribute to preventing and treatingdisease very much influences the health of Canadians.Accreditation Canada is a not-for-profit, independent

organization that provides national and internationalhealth services organizations with quality-focused, com-prehensive accreditation services. Organizations accreditedby Accreditation Canada undergo a rigorous evaluationprocess – based on the application of the standards andtools that are part of the program and trained surveyorsfrom accredited health organizations who conduct an on-site survey to evaluate the organization’s performance.Accredited by the International Society for Quality inHealthCare, Accreditation Canada has supported organiza-tions in improving healthcare quality since 1958. Today,more than 1,000 organizations participate in AccreditationCanada programs every year.The Qmentum accreditation program was introduced to

Canadian healthcare organizations in 2008. Much in thesame way that there are multiple determinants of health,the program is based on a quality framework defined byeight dimensions. These dimensions guide the focus of thestandards. A tag line gives a clear sense of each dimension(Fig. 1). These dimensions must be balanced – emphasis onjust one or two dimensions leads to the risk of ignoringother essential components or determinants of qualityhealthcare.

From Accreditation Canada, Ottawa, Ontario, Canada.Correspondence: Jonathan Mitchell, BSc, MSc, CHE, Accreditation Canada,

1150 Cyrville Road, Ottawa, Ontario K1J-7S9, Canada(e-mail: jonathan.mitchell@accreditation.ca).

Healthcare Management Forum 2012 25:138–1410840-4704/$ - see front matter© 2012 Canadian College of Health Leaders. Published by Elsevier Inc. Allrights reserved.

http://dx.doi.org/10.1016/j.hcmf.2012.07.004

NATIONAL STANDARDS: PROMOTING A FOCUSON POPULATION AND COMMUNITY NEEDS

The Accreditation Canada standards cover all aspects of anorganization’s operations, pertaining to the board, man-agement, staff, services, and patients/clients. A high-per-forming organization must have effective governance andleadership as well as competent staff functioning in effec-tive teams to provide quality care. A focus on only one ofthese elements is inadequate. The standards are developedand updated with input from healthcare experts includingpractitioners, researchers, policy makers, Ministry of Healthstaff, academics, and health services providers at the pro-vincial, territorial, and national levels. Existing initiativeswithin each jurisdiction are also important considerationsin the development process.Population health is a key dimension of the Accredita-

tion Canada quality framework and these standards play aprominent role in the program. As one example, seniorpopulation standards were developed to address the di-verse needs of seniors and to provide guidance to organi-zations in providing services to (1) promote healthy agingand wellness, (2) assist seniors in maintaining their auton-omy and independence, and (3) support families and care-givers. The standards promote senior health by helpingorganizations to focus on prevention and timely screening.Content in the standards includes providing early interven-tions for those identified at risk, and integrating and coor-dinating health services for all seniors across the contin-uum (including primary, community, acute, restorative,long-term, and end-of-life areas of care).During the on-site survey, external peer surveyors assess

the leadership, governance, programs, and services of health-care organizations against national standards. Using a tracermethodology, the process takes a broad, systems perspectiveand evaluates the continuity of services across care areas,such as coordinated information being provided to clients asthey transition to specialized areas of care. Each standardstatement (or criterion) is tagged to a quality dimension,which is clearly identified within each set of standards. Per-

formance in each quality dimension is then reported to each

ble on

THE DETERMINANTS OF QUALITY HEALTHCARE: IMPLICATIONS FOR CANADIAN HEALTH LEADERS

organization. Leaders at all levels of the organization can usethis quality dimension benchmarking, along with self-assess-ment results and the surveyor on-site ratings, to diagnosestrengths and opportunities for improvement in their organi-zations, by unit and by program area.

SAFETY: AN INTEGRAL COMPONENT OFACCREDITATION IN CANADA

First introduced into the accreditation program in 2005,Required Organizational Practices (ROPs) are evidence-based practices that mitigate risk and contribute to im-proving the quality and safety of health services. The ROPsare organized according to patient safety goal areas: safetyculture, communication, medication use, worklife/work-force, infection control, and risk assessment. Examples ofROPs recently introduced in the program include work-place violence prevention (worklife/workforce) and the sur-gical checklist (Communication). Not all ROPs apply to eachsector. For example, a ROP for home safety risk assessmentwas recently introduced for the homecare sector.As with the standards, ROPs share the rigorous develop-

ment process that involves feedback from national partnerorganizations such as the Canadian Patient Safety Instituteand the Institute for Safe Medication Practices Canada.ROPs are supported by extensive research and evidencethat the safety practices reduce risk, and as a result, mor-bidity and costs. The implementation and monitoring ofthe ROPs is one of the ways that Accreditation Canadafosters safe, high-quality care and ongoing quality im-provement.For organizations to improve upon identified opportu-

Figure 1. Accreditation Canada quality dimensions. (Colour figure availa

nities for improvement, information about performance in

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specific institutions, sites, and programs is needed. Forexample, when an organization sets out to reduce thenumber of client falls, measurement of existing practices iscritical in understanding gaps and determining improve-ment options. The on-site survey results provide informa-tion about organizational performance on this particularROP by site, enabling improvement measures to be intro-duced and tracked.Measurement guides the improvement process and al-

lows the organization to monitor progress across pro-grams, services, and sectors, focusing efforts on key prior-ities. Toward that end, Accreditation Canada introducedquantitative tools as part of Qmentum. One such tool, thePatient Safety Culture Tool, is a web-based survey to mea-sure Patient Safety Culture. Validated for the Canadianhealthcare environment by Ginsburg and colleagues,2 thetool captures the underlying dimensions of patient safetyculture, including senior leadership support for safety, su-pervisory leadership for safety, fear of repercussions, re-porting culture, and learning culture (see http://www.yorku.ca/patientsafety for a complete review). The PatientSafety Culture Tool can be deployed as often as an orga-nization chooses, to all staff or to a particular unit, site orstaff group. The tool is administered to measure staff per-ception of the building blocks of safety thereby diagnosingspecific opportunities for improvement.Accreditation Canada released Patient Safety Strategy

Phase 3: Achieving Safe Care as its blueprint for contribut-ing to improving safety in Canada over the next 3 years.Based on partnerships and collaboration with many otherhealthcare quality and safety organizations as well asgovernments, Achieving Safe Care positions the accredita-

-line).

tion program to continue to increase health system safety,

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Mitchell, Nicklin, and MacDonald

foster knowledge exchange and partnerships, and spreadsafety and quality across Canada’s healthcare system.3

QUALITY WORKLIFE: SUPPORTING WELLNESS INTHE WORK ENVIRONMENT

Most definitions of healthcare quality omit reference toworklife. Worklife is a unique dimension of the Accredita-tion Canada quality framework. A focus on staff wellness isa major contributing factor to the provision of qualitypatient care and thus its inclusion in the framework. Phys-ical environment and the context within which one worksare determinants of health and individuals who have a safeworkplace and control over their working conditions arehealthier.1 Quality worklife is essential for the hundreds ofthousands of Canadians who work in Canada’s healthcaresystem as well as to clients. To support this goal, Accred-itation Canada was a founding partner of the QualityWorklife Quality Healthcare Collaborative in 2005, a pan-Canadian initiative to translate evidence-based approachesto building and sustaining healthy work environments.Introduced into the program in 2008, the Worklife Pulse

Tool enables organizations to identify trends, strengths,and opportunities for improvement in their work environ-ments. Using the tool, organizations can plan appropriateinterventions to improve the quality of worklife and de-velop a clearer understanding of how quality of worklifeinfluences capacity to meet strategic goals. The surveytakes the “pulse” of quality of worklife, providing a quickand high-level snapshot of key work environment factors,and individual and organizational outcomes. The tool isnot meant to replace in-depth staff satisfaction surveys,but to be complementary. The Worklife Pulse Tool wasdeveloped by Accreditation Canada in collaboration withthe Ontario Hospital Association, and builds on the earlierHealthy Hospital Employee Survey that was developed inpart by Brock University’s Workplace Health ResearchUnit.4,5 The Worklife Pulse tool can also be deployed asoften as an organization chooses, to all staff or to a par-ticular group. This tool is provided at no additional costand results are provided back to the organization withinhours of completion. In 2012, Accreditation Canada up-dated and strengthened the original Worklife Pulse Tool.

IMPLICATIONS FOR HEALTHCARE LEADERS:QUALITY IMPROVEMENT STRATEGIES FORORGANIZATIONS

The accreditation process and the program elementsdiscussed can benefit healthcare leaders across sectorsand jurisdictions. Organizations stand to benefit fromongoing review and application of the standards, themeasurement tools to track performance over time, aswell as the external third-party review to identify

strengths and opportunities for improvement. Toward

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the goal of fostering continuous quality improvement,the accreditation process promotes a quality improve-ment approach that is embedded into the daily activitiesof the organization. In this way, Qmentum allows orga-nizations to use the information provided as a strategicmanagement tool – to mitigate risk, increase efficiency,and update the organization’s course.

Generating new knowledge: How to improvebased on quality connections

Unique evidence gathered from the accreditation processhighlights the importance of the role and contribution ofthe governing body in safety. A large body of literaturereinforces the importance of governance and its influ-ence on the quality of healthcare services.6–9 However,what tangible results can be observed by comparingorganizations that are exceptionally well-governed withothers that are less so? Accreditation Canada investi-gated this question by analysing the extensive body ofinformation collected from on-site surveys conducted in2009 and 2010.A strong relationship between an organization’s gover-

nance functioning and patient safety was identified.10

“High-performing” organizations in governance were de-fined as those with boards that performed above the 75thpercentile on the Governance Functioning Tool (a surveycompleted by board members as part of Qmentum), andabove the median of all organizations for compliance withthe governance standards. Patient safety was measured bythe overall compliance rate for all ROPs evaluated in theorganization. A significant difference was shown: organi-zations with high-performing boards had a compliancerate of 92% on their ROPs vs a compliance rate of 81% forthe other organizations [high-performing boards, n � 48(15%) vs other organizations, n � 270 (85%), P � .0001].High performance in governance in organizations is asso-ciated with safer and higher quality services being deliv-ered.Using accreditation data, a strong relationship has

also been shown between quality of worklife and pa-tient safety culture.11,12 Based on a sample of staff atCanadian healthcare organizations (�35,000 respon-dents), 71% gave their unit a positive overall grade onpatient safety and 62% gave their organization a posi-tive overall grade on patient safety. At these same Ca-nadian healthcare organizations, 79% felt they couldoften do the best quality work in their job and 63% weresatisfied with their organization overall. These relation-ships between governance and patient safety as well asquality worklife and patient safety culture reveal that theselection of carefully chosen organizational prioritieswill lead to improved results in a number of areas. Inaddition, carefully chosen priorities may prevent a cu-

mulative burden proving to be overwhelming to staff.

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THE DETERMINANTS OF QUALITY HEALTHCARE: IMPLICATIONS FOR CANADIAN HEALTH LEADERS

Using the determinants of quality healthcare forthe purpose of improvement

Toward the end goal of quality healthcare for all Canadians –including efficiencies, fewer errors, and improved clinical andfinancial outcomes – what are the next steps? Supportinghealthcare organizations to focus on the dimensions of qual-ity is critical. There is a unique emphasis in the AccreditationCanada quality framework on population health and worklife.The Qmentum accreditation process continues to be en-hanced to address potential risks through refinements incontent in the standards, ROPs, and measurement tools. Ac-creditation Canada continues to deliver training and shareleading practices and resources with client organizations.Based on national accreditation results, findings and trendsover time across the country are reported, both in terms ofstrengths and opportunities for improvement. In so doing,Accreditation Canada continues to add a unique perspectiveon the healthcare services Canadians receive and assist healthleaders in prioritizing areas for improvement. However, qual-ity healthcare can only be achieved as a shared goal. Incollaboration and partnership with health organizations andteams providing care in all sectors and regions, our contribu-tion continues to improve healthcare quality.

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