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The lead paper, "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Health Leaders," is a valuable contribution to the quality and safety improvement conversations taking place across the country. My commentary suggests a dramatic convergence of social, economic, demographic and technological forces has brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, I have suggested that we need to understand the system not as a structure but as relationships. I argue that alignment is not a concept that is particularly well understood - and we tend to focus almost exclusively on the component of structure.

"Twisting the Lion's Tail" is a valuable and timely contribution to the literature on the need to break down silo thinking and acting. If we stay within a narrow silo by suggesting that researchers generate knowledge, practitioners use the knowledge and then researchers evaluate the results, we will not get to the system thinking view articulated in the lead paper. The author hopes his observations presented in this commentary add to the conversation.

Ontario's Wait Time Strategy--a significant change management initiative--is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006. Change management initiatives are initially successful because of the significant time, attention and resources that are dedicated to the start-up effort. Many initiatives lose their momentum and impact and ultimately fail in the long run since it is difficult to sustain this level of intensity. The probability of success increases if a culture is developed to sustain the initiative into the future. A pivotal element for this sustained culture is accountability for achieving results. If Ontario is to reduce waits for quality healthcare services over the long term, it must shift from a paradigm where no one--or only a few--are accountable for achieving a particular set of results to one where a wide range of players is accountable for achieving a broad range of results. This includes explicit accountabilities of the public, healthcare providers (including physicians, other healthcare providers, professional associations and regulatory bodies), government and Local Health Integration Networks. Tools required to support these accountabilities include developing leaders, aligning incentives to reinforce what needs to be achieved, and developing information systems to provide the data needed to make decisions, and manage and improve performance.

Public performance reporting is an increasingly common health policy tool to support accountability and quality improvement but there are few formal evaluations of this trend. In this review, we suggest that performance reporting may be an effective way to support improvements in performance when it is directed towards groups of providers rather than individuals and that there is enough evidence to support the use and further development of public performance reporting. However, the true impact of performance reporting depends on the policy context around reporting including clarity of strategy, incentives, and support for performance improvement.

Despite the prevailing opinion and consensus around how primary healthcare systems should be changed, there is very little agreement on how this should happen and a surprising paucity of research and evaluative evidence related to both system organization and mechanisms for change. The authors reflect on Ontario's experience with primary healthcare renewal and provide insight into lessons learned.