Table 1.

Policy capacity within health reforms in Canada.

	System level	Organizational level	Individual level
Analytical capacity	Commissions with input from the public and stakeholders (mid-1990s to early 2000s): Romanow, Kirby (Fed); Fyke (SK); HRSC (ON); Clair (QC); Mazankowski (AB) Targeted consultations/advisory panels (after 2005) make actionable recommendations on specific policy challenges, sometimes looking at examples in other jurisdictions (IHI in USA, NHS England) Examples: Baker report on high-performing health systems (2007); Castonguay Report on health system sustainability in QC (2008); Drummond review in Ontario of public administration (2012); SK Advisory Panel on Health System Restructuring (2016); Peachy Report in Manitoba on consolidation (2017); Ernst and Young report in Alberta on power rebalancing and cost (2019–2020); ON Premier’s Council on Improving Healthcare and Ending Hallway Medicine (2019) Auditor General (AG) reports Examples of influence: SK (2015) AG report cast doubt on the Lean program’s return on investment; ON (2019) The AG’s findings that HQO was unable to monitor adoption of its clinical standards helps justify its integration into Ontario Health. Watching other provinces Example: NS adopts zone structure within single health authority after watching AB experience	Performance monitoring and reporting Examples: ECFAA QIPs and hospital report cards (ON), control rooms (QC), WTIS (AB), PCN Panel reports (AB); Saskatchewan Surgical Initiative (SK) Western Canadian Wait List Project (federal funding) Patient input into improvement efforts Examples: Patient/Family Advisory Councils (BC, AB, SK); patient-centred measurement steering committee 2003 (BC); User Committees (QC); CHB role in decision-making (NS) Patients’ First Act (ON); Accreditation Canada standards (federal) Learning from other provinces and jurisdictions (CCN) and from leading centers/jurisdictions abroad (i.e., IHI; England NHS; Virginia Masson)	Mobilize clinical and policy leaders Examples: Cy Frank’s model at Bone & Joint Institute informed SCNs (AB) Recruiting international experts Examples: Don Berwick on first SK HQC Board; Stephen Duckett as first AHS CEO Use of private consultants Example: Lean initiative (SK and QC) Narratives of patient and provider experience Examples: patients going to USA for radiation treatment prompted creation of CCO (ON); BC Fanny Albo case prompted inquiry into LTC (BC); Facebook post by nurse prompted efforts to address nurse staffing ratios (QC)
	Partnering with physicians Examples: tripartite (gov, HA, physicians) type agreements (BC, AB, NS); inclusion of physicians in government planning of reforms (ON 2010 ECFAA; MN 2012 Medical Leadership Council; SK 2018 physicians on teams guiding RHA consolidation) Create arm’s length agencies
	Examples: ICES (ON), MCHP (MN), INESSS, AQESSS, CSBE (QC), Quality Councils (many provinces); CADTH, CIHI, CFHI, CPSI, CCA (Federal)
Political capacity	Public consultation and commissions that give citizens and stakeholders a voice in reform processes Formal agreements with physician associations Examples: trilateral agreement (AB); GPSC (BC); physician participation in transition committee to SHA (SK) Negotiation with health worker unions Creation of intermediate governance bodies and arm’s length agencies Examples: LHINs (ON); Agencies, AQESSS, CSBE (QC); RHAs (persist in BC and MN); quality councils (many provinces) Learning provided to all provincial actors Example: Lean training (SK)	Legislative instruments Examples: laws that give provincial governments power to appoint CEOs and/or boards of organizations; Excellent Care for All Act (ON), Provincial Health Authority Act (SK); RHA Act (AB); Medicare Protection Act (BC); Heath Authorities Act (BC and NS), Bill 10 and 20(QC) Targeted federal funding Examples: Primary Health Care Transition Fund; or Chronic Disease Innovation Fund Citizen and community advisory bodies Examples: PFCC Guiding Coalition (SK); Patient and Family Advisory Groups (AB); Community Health Boards (NS) National campaigns Examples: CFHI, CIHI, Patient Safety Institute; Choosing Wisely Development of collaboration between MoH and stakeholders Examples: Committees to align Ministry plan and physician contracts (AB, BC)	Long-tenured Premiers many provinces see three terms of same political party Experience and implementation-based experts Examples: Jean Rochon, Ken Fyke, Dan Florizone, Matt Anderson, McCann Media attention Examples: nurse staffing problems (SK, QC); system shortcomings (ON cancer radiation care in USA) Inter-provincial movement of experts Examples: Andreas Laupacis on first AHS Board; Ben Chan first HQO CEO after leading SK HQC Participation of provincial experts on national agencies Examples: Sinclair on Infoway Board
Operational capacity (In the case of operational capacity, identical capacities are found at the organizational and individual levels of analysis)	Systemwide policy on performance Examples: Health Results Team and ECFAA (ON); salles de pilotage indicators and GMF targets (QC), wait times strategies (many provinces) Agencies or structures to lead and coordinate improvement efforts Examples: quality councils (many provinces), GPSC (BC), PCN and SCN (AB); FHT (ON); AQESSS, RUIS (QC), CHFI, CPSI (Federal) Agencies to support evidence-based decisions Examples: ICES (ON), INESSS (QC), MCHP (MN), Infoway, CADTH and CIHI (Fed) Centralization of governance structures Bill 10 (QC); single HA (AB, SK, NS), Ontario Health (ON) Private consultants Example: Lean implementation (SK) Incubators to try strategies before broader health system application Example: CCO (ON)	IT infrastructure and comprehensive, timely, comparable data For: harmonized clinical protocols and indicators; indicator tracking and monitoring, practice improvement Self-management programs comprehensive in BC; somewhat available in other provinces Community-driven prevention-promotion only in NS Provider structures to increase provincial ability to direct/influence their activities Examples: PCN (AB), GMF (QC), GPSC (BC) CCAC, FHT (ON) Scope of practice expansion Examples: NPs, pharmacists, emergency services Contracting with private providers Examples: surgical services (many provinces) Tools to better navigate care Examples: telephone triage and information services (all provinces) Coordination/integration among providers Examples: HealthLinks (ON), CI(U)SSS (QC), SCN (AB) Leaders with operational experience Examples: Brown in measurement and improvement (ON) Florizone (Lean), Hudson in academic health (ON), Ducket in health economics (AB), Rochon in population health (QC)

VP: Vice President; DHAs: District Health Authorities; PFCC’: and Fam Patientily Centered Care; HRSC: Health Services Restructuring Commission; SCNs: Stratgic Clinical Networks; HQC: Health Quality Council; AHS: Alberta Health Services; PCNs: Primary Care Networks GMF: Group Medecin Famille; CCAC: Community Care Access Centre; FHT: Family Health Teams; GPSC: General Practice Services Committee; NP: Nurse Practioner; CISSS/CIUSSS: Centres Intégrés de Santé et de Services Sociaux/Centres Intégrés Universitaires de Santé et de Services Sociaux; ICES: Institute for Clinical Evaluative Sciences; INESSS: Institut national d’excellence en santé et en services sociaux; CADTH: Canadian Agency for Drugs & Technologies in Health; CIHI: Canadian Institute for Health Information; HA: Health Authorities; CFHI: Canadian Foundation for Healthcare Improvement; CPSI: Canadian Patient Safety Institute; RUIS: Réseau universitaire intégré de santé; AQESSS: Association québécoise des établissements de santé et de services sociaux; CPAR : Central Patient Attachment Registry; ECFAA: Excellent Care for All Act; QIPs: Quality Improvement Plans; WTIS: Wait Time Information System RHA; LHINs: Local Health Integration Networks; HQCA: Health Quality Council of Alberta; HQO: Health Quality Ontario; CQCO: Cancer Quality Council of Ontario; OHQC: Ontario Health Quality Council; OHA: Ontario Hospital Association; IWK Health Authority: Izaak Walton Killam Health Authority; MCHP: Manitoba Centre for Health Policy.