Leadership accountability for quality: A policy-maker’s perspective

Donald Ferguson, Deputy Minister of the Department of Health, Government of New Brunswick

A province is unlikely to improve the quality of its healthcare system if there is poor communication between the various levels of that system. Healthcare practitioners must communicate effectively with hospital administrators, who must in turn communicate effectively with politicians who control healthcare budgets. Unfortunately, this is rarely the case, says Donald Ferguson.

“The people at each level have their own problems to deal with,” says Mr. Ferguson. “We don’t understand each other enough and we don’t contact each other enough.”

Mr. Ferguson describes a provincial healthcare system as consisting of three planes. At the top, the macro plane, are the politicians who shape healthcare at the population level. They are accountable to the public who elected them. At the bottom, the micro plane, are doctors and nurses and other health professionals who provide services. They are accountable to their patients. And in the middle, the mezzo plane, there are healthcare administrators who help those in the other two planes achieve their goals. They are accountable to healthcare regulatory bodies.

The people in each plane have different obligations to different parties, so it’s no surprise that they sometimes have different ideas on how to improve the quality of care their system provides.

“When a doctor walks into a room and sees a patient who may be dying, he doesn’t think about population-level health. He thinks only about that patient, and that’s a good thing. I want him thinking that way,” says Mr. Ferguson. “However, I care about the state of bedside care not only now, but also 10 years down the road. They have to understand my context better and I have to understand their context better. And the poor hospital administration guys are caught in between, sometimes having to do what is best for their institutions when it may be detrimental to the whole healthcare system.”

Better communication will only come if all parties foster a culture of trust, says Mr. Ferguson. Though agendas may differ, people at one level must at least trust that those at other levels have good intentions. “The various planes in the system don’t talk to each other enough and don’t trust each other enough,” says Mr. Ferguson. “That is where the system is broken down.”

Rather than saying it’s about blame, we should look at it as being about what we can do to improve quality and improve the healthcare system.


Without trust, says Mr. Ferguson, quality accountability structures become difficult to implement. People may view accountability only as a means to administer punishment, rather than a means to improve quality. “When you talk about accountability in healthcare, some people think it’s about looking back at what happened and finding a way to project blame,” says Mr. Ferguson. “Rather than saying it’s about blame, we should look at it as being about what we can do to improve quality and improve the healthcare system.”

At the level in which he works—the policy/political level—those involved in health are held accountable by voters. But that sometimes has little to do with quality, says Mr. Ferguson. Healthcare systems are complicated and the public sometimes focuses more on increasing access to services rather than on an esoteric topic like quality improvement. A politician may feel pressured to make a decision that is popular even if there is little evidence it will improve health outcomes—giving the public what it wants instead of what it needs.

“It’s kind of a fake accountability in a way,” says Mr. Ferguson. “The topics are so complicated, and whoever can communicate them in the simplest manner wins the day.”

It is more important to focus on the appropriateness of health services than on their availability, says Mr. Ferguson. For instance, he notes that doctors in New Brunswick order 60% more CAT scans than the national average, which may in part be because the province has the equipment, not because the scans are necessary.

“We want the waiting list of diagnostic imaging to go down, so we will do a bunch of things to get it down,” says Mr. Ferguson. “But perhaps what we should actually be looking at is if it is appropriate to do so much diagnostic imaging.”

The various planes in the system don’t talk to each other enough and don’t trust each other enough,” says Mr. Ferguson. “That is where the system is broken down.



Another healthcare quality concern revolves around lack of patient volume, a challenge seen across the country. If, for example, a surgical ward in a small community doesn’t have enough patients, the skills of its surgeons may decline. A health planner might recommend that the program be moved to a larger hospital in a larger centre. However, this is only one of the options that should be examined. Such a decision cannot be made lightly and has to include medical professionals and the community at large.

“The public may not understand the safety concerns. Added to that rather significant challenge is the reality that in small communities, the local hospital is more than a facility, it’s part of their identity. Any threat to that identity gets very emotional and government must make sure all options have been examined before deciding on the best approach,” says Mr. Ferguson.

Mr. Ferguson believes quality improvement may soon become more prominent in New Brunswick. In fact, he says, there are plans to create a new quality agenda for the province. New Brunswick couldn’t allot resources to focus on quality improvement over the past two years because of massive structural changes to its healthcare system, having merged eight regional health authorities into two. When you take on such a large organizational change, you tend to focus on the task at hand.

“It’s easy to say you have a quality focus,” says Mr. Ferguson. “But when you are in a swamp, you just try to fend off the alligators.”