Table C1. Empirical results—quotations illustrative of markers of the policy capacities in Wu et al.’s typology.

	Political	Analytical	Operational
System	“the multiple levels of executives in the various DHAs and the various boards was the tipping point politically that definitely was some political attention brought to the multiple VP and CEO roles for a little province that made the change happen”. NS (Interview A0080000b) “When the initiative first started, the ministry did a tour around the province and spoke to various constituents, so staff, physicians, leadership and at that point it was less a consultation on: ‘Will we on will we not consolidate’, it was more about what are the things that matter for healthcare in the future. So, there was, you know, some targeted efforts to do some focused consultation, but also being very strategic, I guess, about what we were consulting on.” (Interview P60002) “A very important legacy of Lean is the critical imperative of involving patients and families and framing the system around their experience.” (Interview P3003) “In about 2008, (a) second period starts up where (…) government starts doing a lot of more external policy work, (..) starting to work much more closely with system leadership on what the policy would look like.” The Ministry overcame initial hesitations about holding very frank discussions on quality, after which “there was a lot of activity really building coalition and consensus.” (..) “The process wasn’t anything well…, incredibly sort of well architected (…). It was really an attempt to generate as much activity as we could either directly or indirectly with almost anyone who was a significant stakeholder in the system (..), groups coming in to work with policy teams in the ministry.” (Interview P5001)	“.. the Patients First Review really helped the system come together and make a commitment that patient and family centered care is what we want healthcare to be.. That was important. Out of the Review came the specific objective from the Ministry of Health to transform the experience for patients requiring surgery.. And from the surgical initiative we get to Lean. So, they’re all connected to me, but that’s how we get to a readiness for leaders to commit to a common improvement method.” (Interview P3006) “The most exciting piece for the Manitoba center is their access to numerous databases, not just the health/administrative databases, but they now have managed to link with housing and justice and so on. So, the center is also really helping us understand our population. We’re just finishing some work with them looking at the impact of social complexities on health and all of the equity pieces.’’ (..) “they (the MCHP) have helped in answering some big policy questions and they have helped in guiding around some specific health service needs.’’ (Interview P4001) “an Alberta Health review of PCNs published in 2016 that found a lot of variation across the PCNs in all areas, including governance, accountability, and service delivery. That review led to the creation of a new governance structure with five AHS zone PCN committees under a provincial PCN committee. That’s been operational since 2017.. so this is enabling the AHS and the PCNs to do some common programming across zones to move resources around based on population need.” (Interview P21030)	“the whole issue of having management zones to bring local decision-making into…, you know, close to where the services are provided would have been one of the things that we learned from Alberta.” (Interview P60001) “That’s what they are: management zones. They’re not separate organizations or that, but that was a really helpful piece of information.” (Interview P60001) “One of the key capacity issue in Manitoba has also been the health human resources and the union structure, which is all being reviewed now. So, Manitoba was one of the few provinces that did not rationalized its unions and collective agreements.” (Interview P4001) “health human resources and union structure now being reviewed; (…) Positions have to be abolished and people re-hired. (…) The new Shared Health organization provides a pivotal point for planning, and should operate as a collective, bringing together policy and operations.” (Interview P4001) “Prior to coming together to form Alberta Health Services, if I had a proposed initiative. I wanted to sell across the province.. you had to sell your new program to each health region by convincing them that this should be a bigger priority than other priorities.. Today, I take proposals straight up to the executive leadership team, maybe saying something like we want to launch a Choosing Wisely campaign across the province in every hospital next year to cut back on waste. If you get support from the executive leadership at that level, it happens. It immediately becomes a priority for every AHS zone in Alberta, whereas before it didn’t become a priority when you had to sell it to the different
	“the minister deserves a lot of credit. She (..) gave a very thoughtful presentation (in the House) on the importance of quality (…) (and has) been a champion of evidence and quality. (..) There was a big team within the ministry, a really good team within the ministry.” (Interview P5001)	“When it comes to the pure quality agenda, it was not long after the creation of the LHINs and the hospital accountability regime that interest began to really surge in patient safety issues. And that was because the experience of other jurisdictions especially in the United States and United Kingdom, which had a growing body of evidence around avoidable errors and critical incidents. (…). That’s really where the quality agenda took its real root.” (Interview P5004)”	regions throughout the province. So for me, it has allowed me to move initiatives and get engagement across the entire province much more effectively.” (Interview P21802) “So, within the hospital sector, we report at the provincial level, the regional level and for indicators at the hospital, named hospital level. For primary care, we actually don’t get that level down, we do not report at the organization level or the physician level. In home and community based care, we have about, you know, nine or so indicators that we use, some of them are at the provincial and the regional level and for a couple of the indicators we go down to the provider level. Long-term care is the same, it is provincial level, regional level as well as individual long-term care home level.” (Interview P501) “The ability to bring these 34 leaders around a table "helped overcome the barrier we often refer to as paralysis in health care.” (Interview P8003) “Here (in Ontario), public health still has its own reporting structure (..), nobody’s talking about social services. So, it’s still very siloed. (..) there are 20 hospitals in our LHIN and we account for 75% of the budget. So, we’re just a hospital-based system, you know, so the LHIN really doesn’t have much money to move around.” (Interview P5006) “However, there was still, in addition to LHINs, a number of other actors that were interfacing with the same range of health service providers and trying to improve quality. Sometimes we achieved alignment, other time not so much.” (Interview P5016)
Organizational	“HQO’s partnership agreements are often around organizations that can mobilize a large group of people who are important in terms of moving things forward.” (Interview P5013) “They issue the broad lines, but the way you manage change within you own box is your responsibility and they give you lots of flexibility in deciding how to manage changes.” (Interview P8002) “We can show the population what we’ve done, and demonstrate it.” (Interview P8001) “The legislation gives us power to integrate, the legislation gives us the ability to stop funding certain services, to start funding new services, so I think we…, on paper there’s quite a lot of power” but the Minister “has the power to veto anything that the LHIN might do”.. “usually about moving resources from one area to another within the system.” (Interview P5016)	“both the IWK and the Nova Scotia health authority as of fiscal 2016–17 had to have a signed off accountability agreement with government. We each had to have one. (…). And their understanding is that as we move along they will become more sophisticated and more explicit in terms of the deliverable.” NS (Interview P60003) “Implementing the control rooms, that brought real added value.. our committee meets every week, in kaizens, (looking at) our annual priorities and then indicators.” (Interview P8003) “You start with an organization that had little accountability and move to organizations that must, at risk of having their budgets cut or other types of administrative penalty, be able to demonstrate their delivery of services. And we went from one extreme to the other in less than two years.” (Interview P8003) “The Wait Times Strategy required hospitals to report on wait times in key areas and also account for the volume of activity that was delivered (..) Working with the OHA, (government developed) accountability agreements, which are essentially a contract between the funder and the hospital that codifies its legal obligations and sets out performance objectives (..); for the first time hospitals were asked to account for their performance in return for the money they were receiving from the province. And that’s proven to be quite an effective tool at improving accountability (..) and a significant factor in improving the financial health of hospitals because it really helped to crystalize mutual expectations between the government and funders.” (Interview P5004)	“The idea was by moving towards activity-based payment we would at least align our incentives towards one dimension of quality, which is really access.” (..) (Interview P5001) “a shared service region that is in charge of all shared services between the regions, which includes lab, diagnostics, physician services and payment, includes the major teaching hospitals in the city, which includes the health sciences center and children’s hospital and women’s hospital and is really designed to start working on that single standard of care.’’ (Interview P4002) “what we have that no other province has — and it’s an unintended impact, but a pretty big one — is that well over 80% of our family physicians who provide comprehensive family care are members of PCNs. So they then elect what they call a physician lead as board chair for their PCN and also elect the physician lead executives for the five zones the AHS is divided into across the province. We actually have an elected body representing over 4000 physicians here in Alberta that is clinical, by which I mean it’s not the Alberta Medical Association."" .. there is a direct line of sight to the clinical practice of family physicians in Alberta through this elected body.” (Interview P21030) “these days, unlike at the beginning, there is a direct grant agreement between any PCN joint venture and Alberta Health. There’s some pretty rigorous documentation accompanying the three-year grant agreement allowing money to flow, which has quite a few requirements as well.” (Interview P21030) “(The Minister seems to consider) the fact that everyone sees everyone else’s results as a motivating factor.” (Interview P8003)
		“hospital report cards that run from about 1998 to 2006 (…) started by the Ontario hospital association and later on supported by government.” (ABR) “Government puts more money behind the OHQC. In 2006-7, Ross Baker leads a commissioned report into high-performing health systems in which he looked at a whole bunch of system around the world and came up with a series of recommendations on what would make those systems better. As well, the CQCO starts to identify areas for improvement, provide support for the clinical leadership council for cancer and other initiatives. In short, there is a much more convincing case for quality and stronger approach to improving quality starts to gain ground.” (Interview P5001)”	“Bill 20 profoundly changed the accountability dynamic of specialized medicine in taking on both hospitalizations and meeting obligations in the ER.. they now have to dedicate someone to respond to emergencies to be sure they get there in time. That changes the whole organization of their days and their distribution of tasks.” (Interview P8002) “There was considerable resistance at first because there were other organizations (Quality and Innovation, the Centre for Quality Improvement and the Quality Improvement partnership - all funded by government) fulfilling the same role, but eventually government gave us a chance to undertake that sort of program, first in long-term care, and train physicians, nurses and administrators to use quality improvement tools.” (Interview P5003).
Individual	“Our deputy minister had experience with Lean and success with it in his region…” and it appeared a good tool to use across the system SK (Interview P3002). “Physicians listen to physicians; it’s important to make them partners.” SK (Interview P3002) “we went into a full year of transition planning, the system and the department together co-lead the CEO from the system and a member of the department who now actually works on this executive team.” (Interview P60001)	“a shared initiative between Alberta Health, HQCA, and a number of other partners that include PCNs. They share their data to create and disseminate patient panel reports to physicians that give them some information about their practice. As we now roll out our new central patient attachment registry (CPAR), the bills will just automatically go to physicians based on their true panel from CPAR.” (Interview P21030)	“The new SHA CEO is a Lean leader, he’s been fully trained and a lot of his senior staff has been trained.” (Interview P3005). “It’ much easier to come to an agreement among 3 people than among 19, ‘said one DG (’C’est pas mal plus simple s’entendre à 3 qu’à 19.” (Interview P8001) “you need to actually get people training in quality (..). So, things like the IDEAS program (…): big system-level capacity development programs are rightfully seen as kind of one of the next stage of ECFAA (..).” (Interview P5001) “Following the JBA initiative, we have hundreds of people in the system with the skills for Lean-based quality improvement.” (Interview P3004)