Leadership accountability for quality: A quality improvement expert’s perspective

by admin admin | Mar 01, 2011

Paula Blackstien-Hirsch, Executive Director, Centre for Healthcare Quality Improvement

A healthcare institution with dozens of quality improvement priorities is most likely an organization with no priorities. The key to organization-wide transformation is focus, says Paula Blackstien-Hirsch. Too often, healthcare providers try to improve many areas at once and end up spreading themselves too thin. According to Ms. Blackstien-Hirsch, this, and lack of attention to factors that facilitate organization-wide culture change, may result in a few “pockets of excellence” but will not lead to system-wide excellence. High-performing healthcare institutions tend to focus on driving the “big dots” that affect overall organizational performance.

“You can really only have two or three priorities at that level.

There is not enough time and not enough resources to do more. To drive change on key indicators, you need to dedicate staff time and resources. The focus must be one of achieving organizational priorities. There must be key messages and communication from the board to the ward,” says Ms. Blackstien-Hirsch. “It’s about alignment, accountability, deployment of resources and it’s about focus. It is a 10- to 15-year journey to really drive key changes and outcomes consistently at that level.”

Ms. Blackstien-Hirsch, who has master’s degrees in health administration and health research methodology, has extensive experience in quality improvement and performance measurement. She has worked in hospital management and hospital consulting, and spent eight years in applied research and quality improvement with the Institute for Clinical Evaluative Sciences. Before accepting her current position, Ms. Blackstien-Hirsch was Director of the Hospital Report Research Collaborative, which developed methods of measuring performance in Ontario hospitals.

At the Centre for Healthcare Quality Improvement, Ms. Blackstien-Hirsch and her colleagues help senior healthcare leaders make quality a key component of their business strategies. It is not good enough, she says, to have a single person in a healthcare organization designated as the individual responsible for quality. Nor will change come from occasionally sending senior executives to conferences on quality improvement.

“You go to a conference and it’s sort of a one-day wonder,” says Ms. Blackstien-Hirsch. “The way to actually effect change is to do actionbased learning. It’s about getting support and coaching and following up over time. It’s about having certain expectations and deliverables, and moving them along a trajectory and making them pragmatic.”

An important part of this learning process is observing organizations that have already learned to focus on major priorities that improve quality at the organizational level. The Centre for Healthcare Quality Improvement has paired Ontario organizations with high-performing organizations in other jurisdictions so they see what putting effective practices into place looks like on the ground. It provides a senior team with a vision of the future state they are aiming to achieve.

A healthcare institution with dozens of quality improvement priorities is most likely an organization with no priorities.


“If you can’t visualize something, you don’t know where you are going” says Ms. Blackstien-Hirsch. “Organizations need to be exposed to the art of the possible, if you will. You have to see what is possible and understand how others have done it.”

After experiencing how successful organizations have improved care, healthcare leaders serious about quality improvement should set goals for their own organizations. For example, a goal could be to reduce serious safety events, such as surgical site infections and falls, by 50% in three years. Though important, simply articulating a lofty goal is only the first step.

You need actual mechanisms for holding people accountable,” says Ms. Blackstien-Hirsch. “Organizations will tell you they have timelines for a lot of projects, but the question is whether they are truly focused, with everything aligned, and whether the projects are linked to organization-wide priorities. It can be hugely empowering and engaging when it’s done in the right way because the staff actually understands how their work is contributing to the organization’s priorities and goals.”

It’s about setting direction from the top and then engaging people from the bottom up.


The primary responsibility for driving quality improvement priorities falls to an institution’s leaders. Hospital boards and senior executives are accountable for the quality of care their organizations provide. Ineffective teamwork at the executive level can sabotage efforts to improve care.

“Leadership is key,” says Ms. Blackstien-Hirsch. “In Ontario, we have some excellent leadership and we have some not-so-good leadership. You need good leadership at the board level and at the executive level. They need to focus on priorities and not get distracted. They need to have the will to effect change. It’s about setting direction from the top and then engaging people from the bottom up.”

In Ontario, healthcare leaders may soon have a big incentive to focus on improving patient care. If the provincial government’s Excellent Care for All Act (introduced on May 3, 2010) passes, the salaries of hospital executives will be directly tied to performance, as measured by quality indicators (such as infection rates, hand-washing compliance).

“In keeping with that, though, the indicators need to cascade down to the ward,” says Ms. Blackstien-Hirsch. “Everyone in the organization has to know what their targets are and what they are accountable for. It has to be built into job descriptions and performance reviews.”

The Ontario government, however, may itself be partially responsible for slowing progress in quality improvement. It is difficult for a healthcare organization to focus on particular areas of care when the government keeps announcing new priorities, says Ms. Blackstien-Hirsch.

“There has to be better alignment at the top, meaning from government,” says Ms. Blackstien-Hirsch. “There are just too many ad hoc, changing agendas.”